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 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, this patient meets the criteria for RTC services.With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to suicidal ideation without plan or intent, and a history of suicide attempts, with the patient reporting five past suicide attempts. The records note a history of self-injurious behaviors in the form of superficial cutting and of impulsivity. The patient reports some homicidal thoughts and thoughts of wanting to torture others. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the records note poor ability to perform activities of daily living. The patient is noted as sleeping excessively and of having insomnia, isolating, and lacking motivation. The patient has not been attending school consistently, reporting that she was expelled from school and is behind on credits. She has pushed away all her friends. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity, due to a history of asthma and insomnia for which she takes clonidine. Sleep disturbance is associated with depression and posttraumatic stress disorder (PTSD), both of which can also exacerbate sleep problems. In terms of level of stress of the recovery environment, the records support a score of 4. The patient has a highly stressful environment, reporting that communication with her mother is poor. The records note high levels of conflict between the patient and her mother, no contact with her biological father, and abuse by her stepfather. The patient reported being expelled from school and is behind in academic credits. With regard to level of support of the recovery environment, the records support a score of 3 due to the patients mother being noted as a trigger to the patient. The patients biological father is not involved in her life, and she has pushed away her friends. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recover management as prior treatment has included outpatient therapy, intensive outpatient program (IOP), partial hospitalization program (PHP), residential treatment center (RTC), and multiple psychiatric hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 2. The patients participation appears adequate. Thus, the patient has a total score of 23. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment noted, the patient meets CALOCUS 5b extended stay criteria.  In this patients case, RTC level of care 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, RTC services 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.