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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services.At issue in this case is whether the RTC services that were provided to treat the patients mental health or substance use disorder were medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). The American Academy of Child and Adolescent Psychiatry (AACAP) & American Association for Community Psychiatry (AACP) have unified the Child & Adolescent Level of Care Utilization System (CALOCUS) & the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the CALOCUS-CASII. This instrument is a standardized tool used to determine the intensity of services needed for children & adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical &/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 & psychiatric conditions;(4) recovery environment (a. stressors and b. supports);(5) resiliency & response to services; & (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 the RTC services at issue.With regard to risk of harm, the records support a score of 4. This dimension assesses a patients potential for harm to self or others, or having harm inflicted upon them. In this case, the patient had a history of suicide attempts & continued to report low levels of suicidal ideation. The patient also had a history of engaging in dangerous sexual behaviors. She was described as impulsive & had a history of impulsivity. Records indicate that the patient hit things when irritated or frustrated. Given the patients history of suicide attempts & impulsive behaviors, her risk of harm was serious. In terms of functional status, the records support a score of 4. This dimension assesses the degree to which a person is able to fulfill responsibilities within developmental constraints. In this instance, the patient struggled with motivation & struggled with completing her activities of daily living such as brushing her teeth & folding her laundry. The patient exhibited poor frustration tolerance, as evidenced by her hitting things. She continued to struggle with mood dysregulation, anxiety, & panic symptoms, & she exhibited serious functional impairment. With regard to co-occurrence of developmental, medical, substance use and psychiatric conditions, the records support a score of 3. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. In this case, patient had significant comorbidity, considering her neurodevelopmental disability of ADHD coupled with depression, anxiety, & sexual dysfunction. In terms of level of stress of the recovery environment, the records support a score of 4. This dimension assesses the stressors in the environment, social circumstances, & interpersonal relationships. Here, patients recovery environment was highly stressful due to her acting out behaviors, which had led her parents to install cameras & to take other measures in their attempt to keep the patient safe. The patients parents reported that they felt like they were their daughters jailer. Furthermore, there were charges pending against an adult male who apparently had a sexual relationship the patient when she was a minor. Other stressors included close friends moving away, death of a close family friend in a plane accident, & death of a family dog who was killed in front of the family. With regard to level of support of the recovery environment, the records support a score of 3. This dimension assesses the presence of family & social support to augment the recovery environment. In this case, the patients parents appeared supportive.In terms of resiliency and response to services, the records support a score of 4. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. In this instance, the patients previous treatment included outpatient mental health treatment, intensive outpatient treatment, partial hospital program, & inpatient psychiatric treatment. Records indicate that patient had not been successful at implementing coping strategies taught at lower levels of care. The patients previous treatment had not achieved completed remission or optimal control of her symptoms, even with intensive &/or repeated exposure to treatment.With regard to engagement, the records support a score of 2. This sub- dimension assesses a child and adolescents ability to form a therapeutic relationship within developmental constraints. In this case, the patients participation was adequate, as evidenced by her attendance & participation in group, family, & individual therapy. These findings give the patient a composite score of 24, which is consistent with Level 5 Medically Monitored Residence Based Services. In addition, under the CALOCUS-CASII framework, the patients scores of 4 for Risk of Harm & Functional Status support treatment at a Level 5 Medically Monitored Residence Based Services level of care. The patients scores under the six-pronged CALOCUS-CASII Dimensional Rating System take into account the specific needs of the patient for the purpose of treating their illness & its symptoms. The CALOCUS-CASII framework for determining the appropriate level of care for children & adolescents needing mental health treatment is consistent with generally accepted standards of mental health, & it provides determinations that are clinically appropriate in terms of type, frequency, extent, site, & duration. The CALOCUS-CASII dimensions are also free from consideration of the economic benefit of the health care service plan & subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the RTC services that were provided to treat the patients mental health disorder were medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue were medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, & is actively practicing, & is an expert in the treatment of the enrollees medical condition & knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.