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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective 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, 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 met the criteria for RTC services.With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to incidents of acting without thinking and physically endangering herself and others,  including assaulting her mother at home. The records noted episodes of the patient jumping out of the car, reporting that she wanted to die of poison, and running out of the home at night with a knife. The patient had a history of psychiatric hospitalization. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to clear reactive attachment behaviors with limited perspective taking and disorganized and disinhibited behaviors. The patient appeared unable to maintain stable relationships in the family. She had a history of multiple suicide attempts and perpetrating physical harm towards family, including stomping on mothers foot and breaking her toe. She had a history of running away multiple times, including an episode of taking a knife with her. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of including PTSD, RAD, developmental delay, and ADHD. The records noted a history of severe malnourishment, neglect, and abuse.  The patient had a history of substance use, being given drugs many times by members of her biological family. The patients biological parents were noted as having a history of alcohol and substance abuse, likely resulting in in-utero drug exposure. The records also indicated exposure to the Chikungunya virus and memory problems. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment as she came to the U.S. from Colombia, requiring her to learn English and adapt to a whole new culture and way of living. School and family appeared to be overwhelming for the patient. With regard to level of support of the recovery environment, the records support a score of 4 as the parents have been trying to support the patient with a stable environment, however, the patients multiple deficits and challenges have overwhelmed parental ability to support this patients needs.In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible resiliency and/or response to treatment, demonstrating an inability to adapt to home/community functioning despite attempts at lower levels of care, which have not been successful in maintaining the safety of the patient or her family.With regard to treatment acceptance and engagement, the records support a score of 3. The patient was unable to engage and utilize skills from treatment.Thus, the patient has a total score of 27. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care was medically monitored intensive integrated services. This is consistent with the level of care that the patient received at the RTC. Therefore, (1) RTC services were medically necessary for the treatment of this patient.At issue is whether (2) RTC services were and are medically necessary for treatment of the patients mental health or substance use disorder for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care, (ii) clinically appropriate in terms of type, frequency, extent, site, and duration, and (iii) 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. Applying the CALOCUS-CASII framework, this patient meets the criteria for RTC services.With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm. The records indicate that the patient continued self-harm and planned to run away from the RTC. She had persistent mood challenges and dysregulation, and internal struggles, and struggled with low self-worth, anxiety, oppositional behaviors, and profanity, although she appears to be getting better. The patient continues to endorse some suicidal ideation without specific plans. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to significant bouts of emotional instability and mood lability. The records noted continued suicidal ideation and self-harm behaviors. The patient had ongoing difficulties with hygiene, such as refusing to shower, and verbal aggression in the form of profanity. Final Result: The reviewer determined that the services at issue were and 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.