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 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, this patient meets the criteria for RTC servicesWith regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of aggression towards family members, and property destruction in the family home, and eloping. He has endorsed suicidal ideation in the past and fashioned a noose which parents found. He has been diagnosed with a psychotic disorder and was noncompliant with his medication.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the records noted that in the months preceding his hospitalization, he was no longer engaging in activities that he used to do such as watching television or interacting with peers. He was hiding in closets or cars. His relationships with family members have deteriorated because of his aggression. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of a primary psychotic disorder and ADHD. The patient had undergone an evaluation for autism. Autism may affect patients insight and willingness to engage in treatment due to cognitive rigidity, while treatment of ADHD with stimulants can exacerbate psychotic symptoms. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment as evidenced by the patients behavior. He is easily upset and becomes highly agitated by various sounds which do not bother the typical individual, and previously did not bother him. He appears to be easily overwhelmed by role expectations that may exceed his capacity given his developmental level. With regard to level of support of the recovery environment, the records support a score of 3 due to his parents efforts to arrange treatment for patient and their participation in treatment, however, the records indicate that community resources have not been sufficient or adequate to meet the needs of this patient prior to hospital admission, showing limited support in the environment.In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as the patients symptomatology has persisted despite multiple treatment attempts at various levels of care including outpatient psychotherapy, psychiatric medication, a partial hospital program, and two inpatient psychiatric hospitalization. With regard to treatment acceptance and engagement, the records support a score of 4. The patients engagement appears to be minimal, as he is intermittently noncompliant with his medications. The records note that the patient has been administered intramuscular medications to ensure compliance. Thus, the patient has a total score of 24. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the requested RTC level of care. 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, RTC services 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.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.