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 
6/16/21 and presented for a nursing assessment. The patients parent has requested reimbursement 
for reimbursement for child mental health RTC services from 6/16/21 through 8/9/21. The Health 
Insurer has denied this request and reported that the services at issue were not medically necessary 
for the treatment of this patient. This denial is the subject of this appeal and determination. The 
physician  reviewer  found  that  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 had a significant risk of harm, due to 
a history of a suicide attempt and significant urges to self-harm. In terms of functional status, the 
records support a score of 3. The documentation noted moderate functional impairment due to 
sensory  issues,  continued  toileting  accidents,  difficulties  with  hygiene  and  with  emotional 
regulation, and  poor  frustration  tolerance.  The  patient  was  noted  as  having  well-developed 
language capacities.  With regard to comorbidity, the records support a score of 3. The patient had 
significant comorbidity, due to a history of concussion in 2017 and hitting her head again the 
following year. The records noted that testing suggested that a residential therapeutic school may 
be necessary, as the patients issues had impacted her learning process.  In terms of level of stress 
of the recovery environment, the records support a score of 3. The patient had a moderately 
stressful environment due to a history of parent-child relational challenges and the patients 
tendency to react emotionally to discussions with her mother. With regard to level of support of 
the recovery environment, the records support a score of 2 as the patients parent was able to 
advocate for her care. In terms of resiliency and treatment history, the records support a score of 
3. The patient had moderate or equivocal response to treatment as the records noted that the patient 
tended to maximize symptoms and minimize capabilities, take a helpless stance, and had a history 
of factitious disordered behaviors. With regard to treatment acceptance and engagement, the 
records support a score of 3. The patient was noted as often attention-seeking. Thus, the patient 
has a total score of 20. In this case, the recommended level of care is medically monitored 
nonresidential-based services. This is inconsistent with the level of care that the patient received 
at the RTC. Therefore, child mental health RTC services from 6/16/21 through 8/9/21 were not 
medically necessary for the treatment of this patient.