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 mental health therapy 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. With regard to risk of harm, the records support a score of 2. The patient had some risk for harm due to passive suicidal ideation and mild substance use.In terms of functional status, the records support a score of 3. The patient had moderate functional impairment, due to the presence of symptoms of depression, anxiety, and panic. The records noted that the patient still looked forward to some activities and saw some friends but had withdrawn socially.  With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity due to some substance use, depression, and anxiety. 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 a stable home with a mother involved in her care but with the patient reporting some frustration and discomfort. With regard to level of support of the recovery environment, the records support a score of 2 due to the patients mother participating in her care. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment as she appeared to have some response to therapy but continued to have symptoms. With regard to treatment acceptance and engagement, the records support a score of 2. The patient appears able to develop a trusting, positive relationship with clinicians and other care providers.Thus, the patient has a total score of 16. This is consistent with low intensity community-based services. In this patients case, weekly individual mental health therapy services are 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, weekly individual mental health therapy 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.