Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, the patient does not meet the criteria for the IOP services.For dimension 1, the patient was at some risk of harm (score 2) due to the patients reports of suicidal ideation when she was younger, which the patient described as not serious. The treatment records do not report any suicidal ideation during the time the patient was in the IOP. The patient had an incident of drinking 1.5 cups of vodka and reported drinking due to stress, but there is no alcohol or other substance use reported during the current IOP treatment. The patient reported a history of cutting and burning herself with unknown frequency and endorsed self-harming by burning marks on her chest with a lighter. There is no report of further incidents of self-harm behavior or any new marks or injuries observed by the providers during the IOP admission. The records document a past history of fleeting suicidal thoughts with no current ideation, plan, or intention and no significant distress. For dimension 2, the patient demonstrated mild functional impairment (score 2) given her evidence of minor impairment in function in family relations with displayed difficulty connecting and communicating with her parents. The patient also showed some impairment in social functioning and difficulty setting boundaries with people. There is some impairment in school functioning as the patient expressed disliking her school and wanting to change schools but she reportedly does well academically. There is evidence of some evidence of minor failures of function in any of several areas of living including school, family, and peers. These periodic or momentary failures are time limited. For dimension 3, the patient has no co-occurrence (score 1). The records indicate that there is evidence of past substance use with reports of drinking when she is under stress. There was no reported or documented drug or alcohol use after the date of the patients enrollment in the IOP. There is no evidence of other medical illnesses, developmental disability, or psychiatric disturbance apart from the presenting condition. For dimension 4A, the patients recovery environment was minimally stressful (score 1) since the patient comes from an intact family with parents who are both employed. There is some strain in family relations but it appears that the family has been working in treatment to address these issues. The patients material needs are met without significant cause for concern that they may diminish in the near future with no significant threats to safety or health. For dimension 4B, the patients recovery environment was supportive (score 2). The provider noted that the patient reported difficulty communicating with her parents. However, the patients parents were actively involved in the patients treatment and participated in family therapy sessions during the time the patient was enrolled in the IOP. The patients family was willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient showed moderate or equivocal resiliency and response to services (score 3) due to previous treatment in the outpatient setting, which the patient stated was a waste of time. The patient demonstrated limited ability to follow through with treatment recommendations during her time in the IOP and was able to maintain recovery from substance use and self-harm behavior throughout the duration of her time in the program. For dimension 6, the patient exhibited limited engagement in services (score 3). The provider charted that the patient participated fully in treatment and was described as being cooperative. However, she was somewhat ambivalent in her relationships with her care providers, expressed difficulty connecting with her therapist, and minimized or dismissed certain symptoms or concerning behaviors. These findings give the patient a composite score of 14, which is consistent with Level 2 low intensity community-based services. In addition, the IOP services were not in accordance with the generally accepted standards of mental health and substance use disorder care,  or clinically appropriate in terms of type, frequency, extent, site, and duration. All told, the IOP services provided were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.