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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly in-person individual therapy with a therapist appropriately qualified to treat young children. 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 weekly in-person individual therapy with a therapist appropriately qualified to treat young children.With regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to passive suicidal ideation, without plan or intent, and without a history of suicide attempts. The records noted a history of self-harm behaviors and of poor frustration tolerance. In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to mood swings, temper outbursts, self-harm, an excessive fear of social situations or public speaking, and avoidance of social situations and of going to school. With regard to comorbidity, the records support a score of 1. The patient has no comorbidity.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to his own regular mood swings and meltdowns and as his parents struggle with depression and anxiety. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents efforts to arrange treatment for patient and their participation in treatment.In terms of resiliency and treatment history, the records support a score of 2. The patient had significant resiliency and/or response to treatment, with prior treatment including weekly outpatient individual psychotherapy and psychiatric care, along with psychotropic medication. With regard to treatment acceptance and engagement, the records support a score of 2. The patient is compliant with medication and is participatory in his sessions with his psychiatrist. The records noted that therapy has been helpful to the patient and that he was working on calm down strategies. Thus, the patient has a total score of 13. In this case, the recommended level of care is low intensity community-based services. This is consistent with the requested level of care. In this patients case, weekly in-person individual therapy with a therapist appropriately qualified to treat young children is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services 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, weekly in-person individual therapy with a therapist appropriately qualified to treat young children are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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.