Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 15-year-old male with a past psychiatric history of attention 
deficit/hyperactivity disorder, other specified depressive disorder, and specific learning 
disorder with impairment in mathematics. The patients parent has requested reimbursement 
for residential treatment level of care provided from 5/28/21 through 12/31/21. 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, the patient met the criteria for RTC services provided from 
5/28/21 through 12/31/21. For dimension 1, risk of harm, the records support a score of 4. This 
dimension assesses potential for harm to self or others, or having harm inflicted upon them. 
The patient has a history of suicidal ideation, self-harm behaviors, and running away. He had a 
history of homicidal ideation towards his mother and sister and had been physically aggressive 
towards them. He is impulsive. For dimension 2, functional status, the records support a score 
of 3. This dimension assesses the degree to which a patient is able to fulfill responsibilities 
within developmental constraints. The patients functioning has improved since being placed in 
residential treatment. However, he continues to struggle with anger dyscontrol, physical 
aggression, and self-harm. Recent gains in functioning have been achieved only while 
participating in residential treatment. For dimension 3, co-occurring 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. This patient has significant co-
occurrence as evidenced by two neurodevelopmental disabilities (attention 
deficit/hyperactivity disorder and learning disorder), depression, and insomnia. Attention 
deficit/hyperactivity disorder is often associated with insomnia and lack of sleep can exacerbate 
attention deficit/hyperactivity disorder symptoms, leading to increased acting out behaviors. 
For dimension 4A, level of stress in the recovery environment, the records support a score of 4. 
This dimension assesses the stressors in the environment, social circumstances, and 
interpersonal relationships. His adoptive parents have expressed not wanting him to return 
home. He has a difficult relationship with his adoptive mother. For dimension 4B, level of 
support of the recovery environment, the records support a score of 3.  This dimension assesses  the presence of family and social support to augment the recovery environment. His adoptive 
parents have not wanted the patient to return home. For dimension 5, resiliency and response 
to services, the records support a score of 3. This dimension assesses how past experiences 
with treatment and recovery might indicate how the patient might respond in the future. Prior 
treatment included residential and psychiatric inpatient treatment. The patient has exhibited 
moderate or equivocal response to current residential treatment placement. For dimension 6, 
engagement of the patient, the records support a score of 3. The child and adolescent sub-
dimension assesses the patients ability to form therapeutic relationship within developmental 
constraints. The patient continued to engage in self-harm behaviors during his treatment stay. 
He struggled to engage in trauma therapy. These findings give the patient a composite score of 
23, which is consistent with Level 5 Medically Monitored Residence Based Services. Per 
CALOCUS-CASII, the childs scores of 4 for risk of harm also supports treatment at with Level 5 
Medically Monitored Residence Based Services level of care. For these reasons, residential 
treatment level of care provided from 5/28/21 through 12/31/21 was medically necessary for 
the treatment of this patient.