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

Findings:  The physician reviewer found that :  The parents of an enrollee has requested reimbursement and prospective authorization and coverage for all or any of the residential treatment center (RTC) services at Newport Academy.At issue is whether all or any of the RTC services at Newport Academy were and are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) 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.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 did not meet the criteria for RTC services.  With regard to risk of harm, the records support a score of 3. The patient ran away from California with the intention of going to New York. The patient made it as far as Arizona before turning themselves in to police. The patient has a history of self-injurious behavior and suicidal ideation, and the patient has taken steps towards acting on his suicidal thoughts.In terms of functional status, the records support a score of 2. The patient reportedly does well in school, has friends, and enjoys a variety of activities. However, the patient ran away from home in reaction to his mothers decision to move to another state. This suggests at least some mild functional impairment.With regard to co-occurrence of developmental, medical, substance use and psychiatric conditions, the records support a score of 2.  The patient has minor comorbidity as evidenced by insomnia and comorbid depression, anxiety, and significant conflict with his mother. There are no medical or substance use comorbidities.In terms of level of stress of the recovery environment, the records support a score of 4. The patients recovery environment is highly stressful. The patients father died when the patient was young. The patient describes a conflictual relationship his mother, whom he describes as emotionally unstable. He had been living with his grandparents prior to admission. The patient has lived in multiple states due to his mother moving frequently. The patient has experienced food insecurity and physical, and emotional abuse. Furthermore, the patient's mother plans to uproot the patient from their grandparents home and move to a different state.With regard to level of support of the recovery environment, the records support a score of 4. The patients recovery environment appears minimally supportive. The patient identifies their partner as a support but does not identify the mother or other family members as support. In terms of resiliency and response to services, the records support a score of 2. According to records, prior treatment has been limited to outpatient therapy following the death of the patients father when the patient was five years of age. The patient has shown remarkable resiliency given the circumstances of their upbringing and the significant adversity the patient has faced.With regard to engagement, the records support a score of 4. The parent sub-dimension assesses the ability of the parents or caregivers to collaborate with the clinician, defining their role in the therapeutic problem, and taking an active role in treatment planning. This patients mother has participated in family sessions but is noted to be focused on behaviors rather than the relationship with her child. The mother is also considering wilderness programs against clinical recommendations. This suggests non-collaborative engagement.  These findings give the patient a composite score of 21, which is consistent with Level 4, Medically Monitored Community Based Services. In this patients case, RTC level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the RTC services at Newport Academy 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.