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 individual therapy. 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. With regard to risk of harm, the records support a score of 2. The patient has some risk of harm, due to a history of suicidal ideation and self-harm behaviors. The patient endorsed intermittent passive suicidal ideation and engagement in self-harm, which have improved since beginning individual therapy. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to mood fluctuations, amotivation, increased fatigue, and difficulty concentrating, with symptoms improving since starting weekly psychotherapy, suggesting that recent gains in functioning have been achieved while participating in treatment. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to the presence of psychiatric diagnoses and a co-occurring medical diagnosis of low ferritin. 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 the stress of the pandemic having adversely affected the patients mood. With regard to level of support of the recovery environment, the records support a score of 2 due to parental advocacy on behalf of the patient and parental participation in treatment. In terms of resiliency and treatment history, the records support a score of 2. The patient has significant resiliency and/or response to treatment. This is the patients first attempt at treatment and the records indicate that symptoms have improved since starting treatment.With regard to treatment acceptance and engagement, the records support a score of 2. The patient has been engaging in treatment. Thus, the patient has a total score of 15. In this case, the recommended level of care is low intensity community-based services. In this patients case, weekly individual therapy is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, 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 individual therapy is 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.