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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for psychiatric adolescent 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). Applying the CALOCUS-CASII framework, the patient meets the criteria for psychiatric adolescent residential treatment center (RTC) services.With regard to risk of harm, the records support a score of 4, which corresponds with a serious risk of harm. The patient has a history of suicidal ideation and self-harm by cutting. She recently attempted suicide by overdose and was hospitalized for several days as a result. She had researched how much medication to take in order to die and had taken more, indicating that the patient was intent on dying by suicide. She has a history of verbal and physical aggression towards her mother. During the period under review, the patient continued to have urges to self-harm. She also endorsed continued passive suicidal ideation and struggled to identify reasons for living.In terms of functional status, the records support a score of 3, which corresponds with moderate functional impairment. The patient uses drugs and alcohol as a way to cope with stressors and problems. Her substance use has led to social withdrawal and isolation. During the period under review, the has patient struggled with self-care and hygiene as evidenced by her disheveled appearance. She also had difficulty tracking conversations and remaining focused, and she has a highly conflictual relationship with her mother.With regard to co-occurring developmental, medical, substance use and psychiatric conditions, the records support a score of 3, which corresponds with significant co-occurrence. The patient has psychiatric issues and substance abuse problems. She also suffers from insomnia. Her substance abuse problems have adversely affected her relationships and functioning. Her substance use has only recently stopped due to her being in a highly structured and protected setting. Depression can cause insomnia and insomnia can exacerbate depressive symptoms.In terms of the level of stress of the recovery environment, the records support a score of 4, which corresponds with a highly stressful environment. The patients father died two years ago, and the patient has a difficult relationship with her mother. Her friend attempted suicide and the patient was not allowed contact with the friend due to the friends hospitalization. In addition, the patients best friend moved to another state recently. The patient believes that no one wants her around anymore. Records also note that the patient was sexually assaulted one month prior to her overdose.With regard to the level of support of the recovery environment, the records support a score of 3, which corresponds with limited support in the recovery environment. The patient reports that her friends are supportive, and notes indicate that she has a conflictual relationship with her mother.In terms of treatment and recovery history, the records support a score of 3, which corresponds with moderate or equivocal resiliency and/or response to treatment. Prior treatment includes several years of outpatient psychotherapy, group therapy, and psychiatric medications. However, the patient has suffered some major losses and has managed to maintain excellent grades despite the losses and stressors.With regard to engagement in services, the records support a score of 3, which corresponds with limited engagement. During the period under review, the patient was noted to be guarded and angry during individual therapy. She expressed little motivation to change at times and expressed plans to resume using substances upon discharge.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 patients score of 4 on risk of harm also supports treatment with Level 5 Medically Monitored Residence Based Services level of care. Accordingly, the psychiatric adolescent residential treatment center (RTC) services at issue and requested services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). 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.