Appeal type: Medical Necessity
Decision: Upheld 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. 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, the patient does not meet the criteria for RTC services.For dimension 1, the patient has been at significant risk of harm (score 3) due to a history of suicidal ideation and the patient reported that she has researched ways to end her life. The patient has taken steps to acquire medication with the intent to overdose as her parents found a bottle of pills hidden in her bedroom. From the first date of denial, the patient has endorsed passive suicidal ideation. She does not have a history of suicide attempts or self-harm behaviors. The records document significant current suicidal ideation with some intent and plan, with an ability for the patient and her family to carry out a safety plan. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) with continued depression, hopelessness, and significant anxiety. The patient has also endorsed difficulty with focus and concentration. The patient has trouble recognizing how her actions impact family dynamics. Recent gains in functioning have been made while participating in treatment in a structured, protected, and contained treatment environment. For dimension 3, the patient has minor co-occurrence (score 2) given her use of alcohol and use cannabis on a weekly basis, which suggests an underlying substance abuse disorder. Occasional, self-limited episodes of substance use are present that show no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4) due to family discord, conflict between father and stepmother, and poor boundaries between parents and the patient. The patient also reports that her father controls her food intake and makes comments about the patients appearance. The records document serious disruption of family and social milieu. For dimension 4B, the patients recovery environment is minimally supportive (score 4) as the patients stepmother is described as helpless and her father is described as controlling. Each parent speaks poorly of the other. The patient describes her home environment as filled with constant parties and photo shoots. The patients biological mother also has mental health issues. There is documentation that the patients family and other primary caretakers display limited ability to participate in treatment and service plan. For dimension 5, the patient has shown significant resiliency and response to services (score 2), especially considering the stressors in the patients life. The records indicate that prior treatment has included outpatient psychotherapy. Overall, the patient has demonstrated average ability to deal with stressors and maintain developmental progress. For dimension 6, the patients parents have exhibited limited engagement (score 3) in the patients treatment. The patients parents are engaged in treatment sessions, although they have been argumentative and blame one another in family sessions. The records indicate that the patients parents have been unable to collaborate in development of service plan. These findings give the patient a composite score of 21, which is consistent with Level 4 medically monitored community-based services. Moreover, the RTC services were not and are not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the RTC services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.