Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 14-year-old female who was admitted to a residential treatment center (RTC) on 
3/25/22 and presented for an admissions assessment. The patients parent has requested 
reimbursement and prospective authorization and coverage for residential treatment services 
from 4/16/22 and onward. The physician reviewer found that at issue is whether residential 
treatment services from 4/16/22 and onward were and are medically necessary for the treatment 
of this patient. The American Academy of Child and Adolescent Psychiatry (AACAP) and American 
Association for Community Psychiatry (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. With regard to risk of harm, the records support a score of 
3. The patient has a significant risk of harm, due to a history of suicidal ideation. The patient and 
her family are able to carry out a safety plan. In terms of functional status, the records support a 
score of 3. The documentation noted moderate functional impairment due to  chronic and 
variably severe deficits in interpersonal relationships, but the patient is noted as having the ability 
to  engage  in  socially  constructive  activities  and  maintain  responsibilities.  With  regard  to 
comorbidity, the records support a score of 2. The patient has minor comorbidity, due to the 
presence of occasional, self-limited episodes of substance use that show no pattern of escalation, 
without indication of adverse effects on functioning or the  patients presenting condition. 
Specifically, the patient has experimented with using alcohol and cannabis but this use has been 
sporadic and shows no pattern escalation. In terms of level of stress of the recovery environment, 
the records support a score of3. The patient has a moderately stressful environment due to an 
interpersonal or material loss that has significant impact on patient and her family, specifically, 
the chronic loss of her fathers involvement in her life. With regard to level of support of the 
recovery environment, the records support a score of 2 due to the patients primary caretaker, 
her mother, being willing and able to participate in treatment if requested to do so and with the 
have capacity to effect needed changes. The patients special needs, including for home/remote 
schooling, are addressed through successful involvement in systems of care. In terms of resiliency 
and treatment history, the records support a score of 3. The patient has moderate or equivocal 
response to treatment due to an inconsistent or equivocal capacity to deal with stressors and 
maintain normal development. With regard to treatment acceptance and engagement, the 
records support a score of 3. The patient acknowledges the existence of a problem, but resists 
accepting even limited age-appropriate responsibility for the development, perpetuation, or 
consequences of the problem. Thus, the patient has a total score of 19. In this case, the 
recommended level of care is high intensity community-based services. This is inconsistent with 
the level of care that the patient was and is receiving at the residential treatment center (RTC).  Therefore, residential treatment services from 4/16/22 and onward were not and are not 
medically necessary for the treatment of this patient.