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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that (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 meets the criteria for RTC services. For dimension 1, the patient has been at some risk of harm (score 2) due to placement on two involuntary psychiatric holds in the past as well as suicidal ideation and has had some intention of acting on these thoughts in the past. The patient reportedly denies current suicidal ideation. The patient acknowledged that he acts impulsively with poor results. He has a history of regular substance use. The records support a past history of fleeting suicidal thoughts with no current ideation, plan, or intention and no significant distress. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given his disrespectful attitude toward peers and maintaining healthy boundaries with others including his parents. The patient was regularly using substances, which interfered with his ability to perform in school and maintain friendships. There is documentation of conflicted, withdrawn and otherwise troubled relationships with peers, adults, and family, but without episodes of physical aggression. For dimension 3, the patient has significant co-occurrences (score 3) given his insomnia and daily cannabis use in recent months as well as past use of alcohol, benzodiazepines, opioids, and cocaine. Substance abuse is present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4). The patient indicated that his father has a bad temper and bipolar disorder, depression, and an alcohol use disorder. The patients older sister is noted to have an eating disorder and her refusal to eat affects the household. The patients father has stated that he cannot live with the patient. The records document serious disruption of family and social milieu. For dimension 4B, the patients recovery environment provides minimal support (score 4). The provider charted that the patient has not had contact with his father in a year and he states that he does not have any friends. The patient expressed that his mother has excessively high expectations for him. The patients mother reportedly sought treatment outside of the patients home state due to lack of community treatment resources and support. Family caretakers are seriously limited in ability to provide for the patients developmental, material, and emotional needs. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to services (score 3) considering the patients struggles to engage actively in treatment, as demonstrated by his minimization of symptoms and lack of engagement in setting treatment goals at the RTC. Also, the patient continued to use cannabis daily and to struggle with low mood and anxiety after two inpatient hospitalizations and outpatient therapy. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has shown minimal engagement in services (score 4). The providers noted that the patients engagement has been inconsistent. The patient is described as highly ambivalent about therapeutic work and he has indicated that he does not need RTC level of care. The records indicate that the patient has not meaningfully engaged in individual sessions and he continues to struggle with motivation. This suggests that the patient accepts no age appropriate responsibility role in development, perpetuation, or consequences of the problem and he exhibits non-collaborative engagement. These findings give the patient a composite score of 23, which is consistent with Level 5 medically monitored residence-based services. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, are clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. Therefore, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are 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.