Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 14-year-old transgender male with a psychiatric history of major depressive 
disorder, generalized anxiety disorder, attention-deficit/hyperactivity disorder (ADHD), gender 
dysphoria,  reactive  attachment  disorder,  factitious  disorder,  unspecified  neurodevelopmental 
disorder with difficulty in social functioning, parent-child relational problem, and academic or 
educational problem. The patients parent has requested reimbursement for the mental health RTC 
services provided from 9/7/21 through 9/24/21. The Health Insurer has denied the services that 
issue is not medically necessary. This denial is the subject of this appeal and determination. The 
physician  reviewer  found  that  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, the patient met the criteria for RTC services provided from 9/7/21 
through 9/24/21. For dimension 1, the patient was at serious risk of harm (score 4) due to a history 
of attempting suicide at least twice and engaging in self-injurious behaviors. The patient endorsed 
longstanding suicidal ideation. The patient has demonstrated physical aggression toward their 
mother. While hospitalized shortly before their admission to RTC, the patient required restraints 
on an almost daily basis to prevent them from self-harming. During the period under review, the 
patient  engaged  in  self-harm  and  was  physically  aggressive  toward  others.  The  patient 
demonstrated current suicidal or homicidal ideation with either clear, expressed intentions and/or 
past history of carrying out such behavior. The patient expressed ambivalence about carrying out 
the safety plan and/or their familys ability to carry out the safety plan was compromised.  
For dimension 2, the patient demonstrated serious functional impairment (score 4) given their 
longstanding  problems  with  hygiene  and  struggles  with  intermittent  bowel  and  bladder 
incontinence. The provider noted that the patient exhibited odd behaviors including growling at 
staff and acting like an animal. The patient was noted to lack any ability to use coping skills. The 
patient engaged in dietary restrictions while hospitalized and showed difficulty expressing their 
needs to staff. During the period under review, the patient engaged in disruptive and unsafe 
behaviors including physical aggression toward staff. The patients participation in school during 
this time was inconsistent. The patient showed a consistent failure to age and/or appropriate to age 
and/or  developmental  level.  Per  the  provider,  the  patient  showed  serious  deterioration  of 
interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, 
which may have included impulsive or abusive behaviors. For dimension 3, the patient has 
significant  co-occurrences  (score  3)  considering  their  diagnosis  of  ADHD,  which  is  a 
neurodevelopmental disability. The patient also has insomnia. Anxiety and depression can cause 
insomnia and conversely, insomnia and lack of sleep can exacerbate anxiety and depressive 
symptoms. Thus, 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 moderately stressful (score 3). Per the provider, the patient is adopted and has a 
conflictual relationship with their adoptive mother. The patient has maintained contact with their 
biological mother and half-siblings on an annual basis. Overall, the role expectations appear to 
exceed the patients capacity given their age, status, and developmental level. For dimension 4B, 
the patients recovery environment was supportive (score 2). The provider noted that the patients 
mother participated in the patients treatment. The patients mother appeared to be supportive as 
evidenced by her advocacy for the patient. The patients family was willing and able to participate 
in treatment if requested to do so and had the capacity to affect needed changes. For dimension 5, 
the patient demonstrated poor resiliency and response to services (score 4) since previous treatment 
has not achieved remission of symptoms or optimal control of symptoms even with intensive 
and/or repeated exposure to interventions. The records indicate that prior treatment has included 
outpatient psychotherapy, psychiatric treatment including psychotropic medications, RTC, and 
two inpatient psychiatric hospitalizations. The provider charted that the patient has a long history 
of complex and refractory behavioral health conditions that have required intensive and specialized 
care. For dimension 6, the patient showed minimal engagement in services (score 4). The providers 
described the patient as unmotivated to participate in treatment and lacked the ability to use coping 
skills. During the period under review, the patient was unresponsive to the staff at times and was 
unable to process precipitating factors or triggers leading to unsafe behaviors. The patient was also 
noted to claim they did not remember their episodes of emotion dysregulation. The patient 
demonstrated a difficult and unproductive relationship with clinicians and other care providers. 
These findings give the patient a composite score of 24, which is consistent with Level 5 medically 
monitored residence-based services. Furthermore, per CALOCUS-CASII, the patients score of 4 
for risk of harm and functional status co-occurrence also supports treatment with Level 5 medically 
monitored residence-based services. For these reasons, the requested RTC services provided from 
9/7/21 through 9/24/21 were medically necessary for the treatment of this patient.