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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for weekly in-person therapy sessions. 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 weekly in-person therapy sessions.With regard to risk of harm, the records support a score of 2. The patient has some potential for risk of harm, due to poor frustration tolerance and passive suicidal ideation without plan or intent. The records did not note a history of suicide attempts or self-harm. In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to hyperactivity, bouncing off the walls, irritability and outbursts if limits were placed on use of electronics.With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to the presence of psychiatric diagnoses and medical diagnosis of constipation. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment as the patients parents reported that the patient becomes upset when limits are placed on electronic use. With regard to level of support of the recovery environment, the records support a score of 2 due to the patient's mothers advocacy efforts on the patient's behalf.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to services. The records note that prior treatment has included psychiatric care, outpatient therapy via virtual visits, and psychotropic medication., and suggest that the patients attention deficit hyperactivity disorder (ADHD) symptoms interfere with ability to utilize virtual counseling sessions.With regard to treatment acceptance and engagement, the records support a score of 3. The patient is compliant with medication. While the patient is participatory in sessions with psychiatrist, the patient's ADHD symptoms impair ability to fully engage in and utilize virtual psychotherapy sessions. Thus, the patient has a total score of 16. In this case, the recommended level of care is low intensity community-based services. In this patients case, weekly in-person therapy sessions are 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, weekly in-person therapy sessions 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.