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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient multidisciplinary assessment (completed inpatient; over a six to eight week period; at a comprehensive assessment facility, licensed as a specialty psychiatric hospital; specifically for children 12-17 years of age) while also providing weekly psychiatric sessions for medication management and full psychiatric evaluation. 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 4. The patient had a serious risk of harm, due to a history of overdose resulting in hospitalization upon being found unconscious. The records noted a suicide attempt, a history of unpredictable and threatening behavior, and impulsivity. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to ongoing struggles with family members, not complying with parental rules and expectations, poor academic performance, and a return to substance use. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of neurodevelopmental  and psychiatric diagnoses coupled with polysubstance use disorder. His medical history is notable for asthma. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to his acting out behaviors, failure to follow parental rules, and continued substance use, leading to conflict between the patient and his mother. With regard to level of support of the recovery environment, the records support a score of 4 due to serious limitations in access to the needed and recommended mental health services as evidenced by lack of appropriate aftercare following his discharge from residential treatment.  In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible resiliency and/or response to treatment due to persistent symptomology despite treatment at multiple levels of care. The patients treatment in the last year includes at least inpatient psychiatric hospitalization, residential treatment stays, and PHP.  The patients treatment history included treatment at multiple levels of care along with psychotropic medication and multiple medication trials since early childhood. With regard to treatment acceptance and engagement, the records support a score of 3. The patient has a history of not engaging with treatment and superficially engaging in treatment, treating it as a game.Thus, the patient has a total score of 26. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. In this patients case, RTC level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the 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, inpatient multidisciplinary assessment (completed inpatient; over a six to eight week period; at a comprehensive assessment facility, licensed as a specialty psychiatric hospital; specifically for children 12-17 years of age) while also providing weekly psychiatric sessions for medication management and full psychiatric evaluation are 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.