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

Findings:  The physician reviewer found that The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. 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. Applying the CALOCUS-CASII framework, this patient meets the criteria for RTC services.With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to rare suicidal ideation without a history of suicide attempts or self-harm behaviors. The records noted a history of physical aggression, property destruction, anger dyscontrol, and impulsivity. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to a significant decline in grades, with the patient refusing to attend school and not having attended school for several weeks. The patient was not getting along with the mother, and was verbally and physically aggressive towards the mother. The patient was not sleeping well, impulsive, struggled with peer interactions, and had a physical altercation with a peer while at the RTC.With regard to comorbidity, the records support a score of 4. The patient has major comorbidity, due to the presence of a neurodevelopmental disorder, attention deficit hyperactivity disorder (ADHD), alcohol use disorder, and insomnia, all of which can exacerbate depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms. Conversely, insomnia can be a symptom of depression, anxiety, and PTSD. Insomnia is also common in ADHD. The patient was noted as drinking alcohol every other day, and alcohol use can contribute to depressive symptoms, reduce inhibitions, and lead to behavior dysregulation and other impulsive behaviors. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment. The patients parents are divorced and have a highly conflictual relationship. The patient did not have contact with the father and a strained relationship with the mother and the mother's partner. The patient reported that their father was abusive to them and the mother and that the father had threatened to kill the mother multiple times. The patient was not doing well in school and had failed the last semester. The patient's mother was noted as having depression, PTSD, and self-harming behaviors, and was enrolled herself in a partial hospitalization program (PHP). The patient reported that the current home was triggering PTSD. With regard to level of support of the recovery environment, the records support a score of 2 as the patient was not in contact with the father. The patient's mother and her partner were participating in family therapy, although the patient was noted as having a strained relationship with the mothers partner. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as prior treatment has included multiple medication trials, intensive outpatient program (IOP), residential treatment, and inpatient psychiatric hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 2. The patient appears engaged in treatment as evidenced by attendance and participation in individual, group, and family therapy. However, at times he is impulsive in groups and off-putting to peers. Thus, the patient has a total score of 23. The records support a 4 in terms of functional status and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and comorbidities noted, the patient meets CALOCUS 5b extended stay criteria. This is consistent with the level of care that the patient was and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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 and are medically necessary for the 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.