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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective 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 had a serious risk of harm, due to a history of multiple suicide attempts and self-harm behaviors. While at the RTC, the patient eloped and was hiding items could have been used to self-harm. The records note that the patient is impulsive, has poor judgment, and has difficulty regulating his mood. The patient is transgender, a known risk factor for suicide. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to struggles with maintaining hygiene and social relationships, and poor physical boundaries. The patient struggles with managing interpersonal conflict. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of attention deficit hyperactivity disorder (ADHD), a neurodevelopmental disorder, gastrointestinal problems, and psychiatric diagnoses. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to social struggles that are adversely impacted by the patients communication and emotional challenges, as the records note that the patient irritated his peers. The patient identifies as transgender and while the records note that the parents are mostly supportive, there is significant conflict between the patient and his parents. With regard to level of support of the recovery environment, the records support a score of 3 as the parents appear supportive of the patient, however, community resources only partially compensate for unmet emotional and educational needs. 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 outpatient psychotherapy, psychiatric care including psychiatric medications, a group therapy program, and two psychiatric hospitalizations. The patient demonstrates frequent evidence of innate vulnerability under stress and difficulty resuming progress towards an expected developmental level. With regard to treatment acceptance and engagement, the records support a score of 3. The patient appears engaged in treatment but struggles with openness around feelings. Thus, the patient has a total score of 24. The records support a 4 in terms of functional status and risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets CALOCUS 5b extended stay criteria.  This is consistent with the level of care that the patient was and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and 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 were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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.