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

Nature of Statutory Criteria/Case Summary: The patients parent 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 met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4) due to a history of attempting suicide on more than one occasion. The patient surreptitiously obtained items to engage in self-harm and she reportedly self-harmed on multiple occasions during the RTC admission. The patient also threatened to elope from RTC several times. There is documentation of current suicidal ideation with a past history of carrying out such behavior. There is also indication or report of significant impulsivity and poor judgment that was significantly endangering to self. For dimension 2, the patient demonstrated serious functional impairment (score 4) since she struggled to manage her emotions as evidenced by punching walls and throwing food items around her room. The patient was often rude to peers and staff, intermittently argumentative, and she struggled to comply with basic expectations. The patients participation and effort in school was poor. The patient showed serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. For dimension 3, the patient has significant co-occurrence of conditions (score 3) given her history of polysubstance use and insomnia. Both substance use and insomnia can exacerbate mood and anxiety symptoms and conversely, anxiety and depression can exacerbate insomnia and contribute to ongoing issues of self-medicating with substance use. There is evidence of medical conditions that may have adversely affected, or been affected by, the presenting condition. In addition, substance abuse was present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment was highly stressful (score 4). The provider noted that the patient was sexually assaulted, and the case was being prosecuted. The patients parents are divorced, and she has longstanding and ongoing conflict with her parents. Her parents have been unable to manage her significant acting out behaviors. The records document serious disruption of family milieu. For dimension 4B, the patients recovery environment provided limited support (score 3). The records document that the patients parents were supportive of the patient. However, community resources only partially compensated for unmet emotional and educational needs. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4). The patient demonstrated frequent evidence of innate vulnerability under stress and difficulty resuming progress toward expected developmental level. Prior treatment has included outpatient psychotherapy, psychiatric care including psychiatric medications, an intensive outpatient program, two partial hospitalization programs, residential treatment including a wilderness program, and a psychiatric hospitalization. For dimension 6, the patient exhibited minimal engagement in services (score 4) due to the patients disruptive and argumentative behaviors during groups, and intermittent struggles to participate in groups and milieu activities. The patients engagement in family and individual therapy sessions was inconsistent. The patient did not accept age-appropriate responsibility for their role in the development, perpetuation, and consequences of the problem. These findings give the patient a composite score of 26, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS-CASII, the patients scores of 4 for risk of harm and functional status also supports treatment at Level 5. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the RTC services were medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 subspecialty 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.