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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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 did not meet the criteria for RTC servicesWith regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to a history of exhibiting poor judgment. While at the RTC, the patient struggled at times with appropriate boundaries with a male peer.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as her recent gains in functioning have been achieved while participating in the structured residential treatment program. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of autism, along with depression, anxiety, insomnia, and constipation.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 role expectations exceeded the patients capacity, given her age and developmental level. With regard to level of support of the recovery environment, the records support a score of 3 due to a generally supportive environment; however, the records suggested that community resources only partially compensated for unmet emotional needs.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment as prior treatment, including family therapy, psychiatric medication, outpatient therapy and an IOP has not been successful in optimal control of symptoms. With regard to treatment acceptance and engagement, the records support a score of 3. The patient engaged in treatment, although she struggled with cognitive distortions and staff feedback. The records noted that the patient minimized and/or rationalized her behaviors and struggled with accepting even age-limited responsibility for her role in her problems. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. This is inconsistent with the level of care that the patient received at the RTC. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, RTC services provided  were not medically necessary for the treatment of this patientFinal Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.