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

Findings:  The physician reviewer found that 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 4. The patient has a serious risk of harm. The patient denies suicidal ideation, but has a history of self-harm behaviors, polysubstance use, running away, and engaging in high risk, dangerous, and potentially lethal behaviors such as driving at high speeds while evading the police while under the influence of substances without a license and has a history of impulsivity. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient has been skipping school and is failing classes. The patient has run away from home for over ten days, being brought back home by the police. The patient has not been following parental rules and has been threatening the parents. There is significant and consistent conflict in interactions with parents. The patient has been cited by the police for drug possession. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity, due to the presence of a developmental disability, ADHD, polysubstance use disorder, and asthma. Treatment for asthma may exacerbate symptoms of anxiety. In terms of level of stress of the recovery environment, the records support a score of 4. The patient has a highly stressful environment due to significant conflict between the patient and parents regarding the patients ongoing acting out behaviors. The patient has been charged with a misdemeanor and has an upcoming court date. The patient has lost friends due to substances use and is failing in school. With regard to level of support of the recovery environment, the records support a score of 2 as the patients parents appear supportive as evidenced by their willingness to seek treatment for patient. However, the patients peer group appears unhealthy and troubled.  In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as prior treatment has included longstanding outpatient psychotherapy, psychotropic medication, and two emergency department visits due to unsafe behaviors.  With regard to treatment acceptance and engagement, the records support a score of 2. The patient is noted as being moderately motivated for treatment. Thus, the patient has a total score of 24. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment, elevated risk of harm, and comorbidities 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.