Appeal type: Medical Necessity
Decision: Overturned 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 is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (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, this patient met the criteria for RTC services. For dimension 1, the patient was at significant risk of harm (score 3) due to ongoing suicidal ideation, and multiple depressive and anxiety symptoms. The patient continued to exhibit labile moods. She reported a poor body image as well as severe urges to self-harm. The patient has a history of three past suicide attempts as well as chronic poor impulse control and reactivity. The records support indication or report of incidents of acting without thinking. For dimension 2, the patient demonstrated serious functional impairment (score 4) since she continued to demonstrate poor interpersonal functioning while at the RTC, and she consistently reported high anxiety, irritability, self-harm urges, and suicidal ideation. The records document that the patient became escalated at times and she also threatened to punch a peer. The patients poor self-regulation, bouts of mood lability, and aggressive behaviors continued while at the RTC. The records document serious deterioration of interpersonal interactions with consistent conflict and otherwise disrupted interactions with others, which include impulsive and aggressive behaviors. For dimension 3, the patient has major co-occurrences reported (score 4). The patient has a history of major depressive disorder, generalized anxiety disorder, and parent-child relational problems. Also noted are ongoing suicidal ideation and self-harm urges. Psychiatric symptoms were present that impaired functioning, persisted in the absence of stressors, and seriously impaired recovery from the presenting condition of suicidal ideation and self-harm. For dimension 4A, the patients recovery environment was highly stressful (score 4). The records document that the patients parents are divorcing, and the patient has endured a high level of family stress due to family tendencies for criticism. This supports serious disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) since the patients family appeared to be overwhelmed by the patients behaviors. The patients family had limited ability to respond appropriately to the patients developmental needs and problems or was ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient exhibited poor response and resiliency to services (score 4) due to previous treatment in the outpatient setting with limited results. The patient continued to struggle at RTC level of care with limited progress despite therapy and medication management. The patient demonstrated evidence of frequent innate vulnerability under stress and difficulty resuming progress toward expected developmental level.For dimension 6, the patient demonstrated minimal engagement (score 4). The records document that the patient maintained a difficult and unproductive relationship with clinicians and other care providers. Overall, the patient continued to demonstrate tendencies for sabotaging relationships and difficulties with adapting therapeutic coping skills for managing their mood lability, irritability, and depression and anxiety symptoms in general. These findings give the patient a composite score of 26, which is consistent with medically monitored intensive integrated services: non-secure, 24-hour service with psychiatric monitoring. Moreover, the RTC services provided were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.