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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services.Findings:  The physician reviewer found that American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (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 provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. 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) developmental, medical, substance use and psychiatric comorbidity; (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 met the criteria for RTC services. For dimension 1, the patient was at extreme risk of harm (score 5) due to a low weight of 79 pounds when he was admitted to an acute care facility prior to transferring to RTC. The patient was at 58% of his ideal body weight (IBW), which was dangerously low. The patient was malnourished and tachycardic. When he was transferred to RTC, he was at 60% of his IBW. The patients weight increased to 74% of his IBW. This is still significantly underweight and below his typical weight in the fifth percentile and with a goal weight of 105 pounds. The patient was frequently documented to not be finishing his snacks and meals and on occasion he refused to eat completely. The patient required significant prompting and redirection to engage in eating. His trajectory of weight gain appears to have only been possible in the highly structured environment of RTC as he failed to continue to gain weight after discharge to a lower level of care. The patients inability to maintain a healthy weight was a clear indication of repeated behavior that was injurious to himself and his persistent meal refusals were indicative of the patient relentlessly engaging in acutely self-endangering behaviors. For dimension 2, the patient demonstrated serious functional impairment (score 4) due to serious deficits in interpersonal interactions with other patients and staff at the RTC. The provider noted that the patient was loud, disruptive, argumentative, non-compliant, challenging, and did not follow simple directions despite multiple prompts. On one occasion, the patient rolled around in a chair and over another patients foot causing injury to the patient. The patient displayed constant failure to achieve self-care at age appropriate levels by his refusals to eat and he required significant prompting to finish meals. For dimension 3, the patient has significant co-occurrence (score 3) given his diagnosis of autism spectrum disorder, which is a developmental disability that can reduce functional capacity and adversely affect his presenting condition. The patients malnutrition resulting from his eating disorder is a serious health condition that required significant medical monitoring and his nutritional status was adversely affected by his eating disorder. Anxiety and depression are also significant psychiatric co-morbidities that could have complicated his course of treatment. The records document that medical conditions were present that may have adversely affected, or been adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment was highly stressful (score 4). The provider noted that the patients parents are recently divorced and their relationship continued to be conflicted and strained as evidenced by their arguing in family therapy sessions and inability to agree on the best management for the patients condition. Per the treatment notes, the patients parents struggled to enforce appropriate limits for the patients behavior which is impaired their ability to properly adhere to the patients eating plan and allow him to gain weight. There is documentation of serious disruption of family or social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3). The provider charted that the patients parents participated in his treatment but were noted to demonstrate only partial ability to make necessary changes during treatment due to their disagreement on the patients treatment, difficulty managing the patients behavior, and adhering to his eating plan. The patients parents appeared to struggle co-parenting and maintaining consistency between the two homes. For dimension 5, the patient showed negligible resiliency and response to treatment (score 5) given the impact that the COVID-19 pandemic had on the patient causing significant turmoil to the patients routine, which led to developmental regression and worsening of his eating disorder, as well as the need for acute hospitalization for malnutrition. The patients restricted eating persisted while he was in RTC and he required significant prompting to eat his meals and snacks. Even in this highly structured setting, the patient still failed to complete meals and reach his goal weight. The patient was documented to be argumentative and uncooperative with RTC staff and appeared to have poor insight into the severity of his eating behaviors. The records document that the patients symptoms were persistent and functional ability showed no significant improvement despite receiving intensive services. These findings give the patient a composite score of 28, which is consistent with Level 5 medically monitored residence-based services. Per LOCUS placement criteria, the patients scores of 5 for risk of harm, and co-morbidity and 4 for functional status also support treatment at Level 5. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the RTC services were medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 subspecialty