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

Findings:  The physician reviewer found that The patient has requested reimbursement 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, the patient did not meet the criteria for RTC services.For dimension 1, the patient was at significant risk of harm (score 3) due to prior history of suicide attempts on at least two occasions. The patient also has a remote history of self-harm behaviors in the form of scratching arms. On admission to the RTC, the patient denied suicidal ideation. The records document no active suicidal or homicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given the struggles to comply with parental expectations prior to admission. The patient and parents experienced difficulties with communication. The records do not indicate that the patient experienced any significant problems during treatment. The patient has maintained above average grades in high school. The records document chronic or variably severe deficits in interpersonal relationships, but with ability to engage in socially constructive activities, and ability to maintain responsibilities. For dimension 3, the patient had minor co-occurrence of conditions (score 2) considering the patients psychiatric diagnoses including oppositional defiant disorder and unspecified depressive disorder, as well as cannabis use disorder. The patient has a long history of using cannabis and other substances. The provider noted that the patient had not used substances for several months. The records document occasional, self-limited episodes of substance use were present that showed no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The patient reported having a strained relationship with family members. The patient recalled being negatively impacted by the suicide of a girlfriend several years prior. There is evidence of disruption of family and social milieu. For dimension 4B, the patients recovery environment was supportive (score 2). The provider charted that the patients parents were supportive of patient and attempts at treatment. The patients family was willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient exhibited moderate or equivocal resiliency and/or response to services (score 3) since previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Prior treatment has included psychiatric medication, a wilderness therapy program, and one month of residential treatment. For dimension 6, the patient showed limited engagement in services (score 3). The records document that the patient appeared adequately engaged in treatment. However, the provider noted that at times the patient was guarded in groups and defensive in family therapy. The patient acknowledged the existence of problem but resisted accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 19, which is consistent with Level 4 medically monitored community-based services. In addition, the RTC services were not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the RTC services were not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.