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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for intensive in-home family treatment. 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. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to a history  multiple suicide attempts, and ongoing suicidal ideation and self-harm behaviors. In terms of functional status, the records support a score of 3. The documentation notes moderate functional impairment as evidenced by multiple visits to the emergency department and several inpatient hospitalizations, which has likely interfered with her schooling. The patient endorses depressive symptoms and is noted as being unable to function in the social setting. With regard to comorbidity, the records support a score of 1. The patient does not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a moderately stressful environment as the patient had made allegations of abuse in the home resulting in investigation. The patient reports not having friends and being lonely. She has minimal coping skills and it appears that role expectations exceed the patients capacity to cope. With regard to level of support of the recovery environment, the records support a score of 3 as the records suggest that the patients parents may have difficulty setting appropriate limits for their daughter. The family has limited ability to respond appropriately to the patients developmental needs and/or problems, as the patients parents have declined various levels of care, indicating that they may not be consistently following treatment recommendations. 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 treatment including dialectical behavior therapy (DBT), multiple medication trials, intensive outpatient program (IOP), partial hospitalization program (PHP), crisis residential treatment, and at least two inpatient psychiatric hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 3. The records suggest that the patient has refused to engage in recommended treatment in the past and struggles to utilize coping skills. She is noted as lacking motivation. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. This is a higher level of care than the requested intensive in-home family treatment. In this patients case, intensive in-home family treatment is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services 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, intensive in-home family treatment is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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.