Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 15-year-old male who was admitted to a residential treatment center on 2/15/23 
and  presented  for  a  biopsychosocial  assessment.  The  patients  parent  has  requested 
reimbursement for mental health residential treatment from 2/15/23 through 4/26/23. The 
Health Insurer has denied this request and reported that the services at issue were not medically 
necessary for the treatment of this patient. 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, this patient met 
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 suicidal ideation, self-harm, and two suicide 
attempts. The patient reported that his last incident of self-harm occurred two weeks prior to 
admission. He denied suicidal ideation at the time of admission and throughout his stay in RTC. 
The records noted a history of aggression, property destruction, and running away from home. 
The patient had a history of significant and regular substance use. During the period under 
review, the patient engaged in self-harm, was involved in a verbal altercation with a peer, and 
inhaled cleaning products with the intention of getting high. The patient exhibited a clear and 
persistent inability, given his developmental stage, to maintain physical safety and/or to use the 
environment for safety. The patient exhibited significant impulsivity and physical aggression. In 
terms of functional status, the records support a score of 4. The documentation noted serious 
functional impairment as the patient was not attending school due to his mental health and 
behavioral issues. He had been suspended and then expelled for fighting and truancy. The patient  
struggled to focus when subjects were not easy for him. The records noted that the patient 
struggled to speak to staff respectfully and had difficulty managing his frustration and anger, 
getting upset and yelling. He required frequent redirection due to his poor boundaries and 
impulsive behaviors. The records noted that lying, sneaky behavior, boundary crossing, and poor 
impulse control continued to be problems for the patient during the period under review. With 
regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, 
due to the presence of a neurodevelopmental disorder, ADHD, and a substance use disorder. The 
patients use of substances adversely affected his mood and anxiety. The patients poor impulse 
control secondary to ADHD likely contributed to his substance use. In terms of the level of stress 
of the recovery environment, the records support a score of 3. The patient had a moderately 
stressful environment. The patients biological mother was deceased. He had a conflictual  relationship with his father and stepmother and left their home in the fall of 2022 due to his 
behavior. The patient was living with his uncle but was no longer welcome to return due to his 
behaviors. His father is described as volatile, verbally aggressive, and inattentive/disengaged at 
times.  The records noted that the patient was to be discharged to live with his aunt in another 
state. With regard to the level of support of the recovery environment, the records support a 
score of 2 as the patient reported that his peer group used substances. His family, including 
extended family members, appeared supportive. In terms of resiliency and treatment history, the 
records support a score of 4. The patient had poor resiliency and/or response to services as prior 
treatment  has  included  outpatient  psychotherapy  and  psychiatric  care  including  multiple 
psychotropic  medications,  psychiatric  residential  treatment  centers,  and  several  inpatient 
psychiatric  hospitalizations.  Previous  treatment  has  not  achieved  complete  remission  of 
symptoms or optimal control of symptoms and the patient demonstrates frequent evidence of 
innate  vulnerability  under  stress  and  difficulty  resuming  progress  toward  the  expected 
developmental level. With regard to treatment acceptance and engagement, the records support 
a score of 4. The patient engaged in ongoing disrespectful behavior towards staff. The patient 
appeared  superficial,  minimized  his  problems,  and  underreported  his  symptoms  to  his 
psychiatrist, generally answering questions in a positive manner. The patient did not appear to 
accept  age-appropriate  responsibility  for  his  role  in  the  development,  perpetuation,  and 
consequences of his problems. 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 received at the residential treatment center. Therefore, mental 
health residential treatment from 2/15/23 through 4/26/23 was medically necessary for the 
treatment of this patient.