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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that 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. Applying the CALOCUS-CASII framework, this patient met the criteria for RTC services.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to near daily thoughts of being better off dead along and a history of at least one suicide attempt. The patient endorsed self-harm due to significant distress around her meal plan and weight restoration. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to the patient requiring a significant amount of support from treatment staff to comply with her meal plan. She continued to engage in numerous disordered eating behaviors such as attempts to avoid food and fluid intake and maladaptive coping methods during mealtimes including taking micro-bites, inappropriate napkin use, and picking at her food. The records noted that the patient struggled to talk to peers. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity, due to the presence of anorexia nervosa, restricting type, which can have multiple medical sequelae including cardiac arrhythmias, orthostatic hypotension, bradycardia, leukopenia, anemia, delayed gastric emptying, constipation, and others. The patient had a prescription of a standing dose of metoclopramide, suggesting presence of nausea, gastroesophageal reflux disease (GERD), and/or delayed gastric emptying. Lack of appropriate nutrition can worsen psychiatric symptoms including mood and anxiety disorders, while mood/anxiety symptoms can lead to reduced dietary intake in those with and without eating disorders. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to significant stress around eating and body image during the period under review. She reported difficulty connecting with her family and that she did not trust her parents.  With regard to level of support of the recovery environment, the records support a score of 3 as the patients family appeared supportive, but the patient reported difficulty connecting with her family through family therapy and that her parents were unable to provide adequate support.In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as prior treatment included outpatient psychotherapy, psychiatric treatment including medication management, and several hospitalizations for anorexia nervosa, suicidal ideation, and a suicide attempt.  With regard to treatment acceptance and engagement, the records support a score of 4. The patient continued to engage in eating disordered behaviors including questioning portion sizes and not consuming adequate fluids. She was noted as distrustful of treatment providers and struggling to engage with staff, and questioned her meal plan, suggesting an unproductive relationship with care providers, disruption of services, and minimal engagement. Thus, the patient has a total score of 26. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received at the RTC. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, RTC services were medically necessary for the 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 sub-specialty 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.