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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for psychiatric hospital inpatient treatment. Findings:  The physician reviewer found that 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, the patient did not meet the criteria for psychiatric hospital inpatient services.For dimension 1, the patient was at serious risk of harm (score 4) due to history of suicide attempt by overdose although she stated that it was not a suicide attempt but was intended to express  her pain to others. The patient reported that her ingestion of Tylenol was impulsive, and she indicated that she did not know when that might happen again. During her stay, the patient continued to express that she would continue to have suicidal ideation if she went to her fathers house. The records support indication or report of significant impulsivity, with poor judgment and insight that were significantly endangering to self or others. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given her increasingly melancholic mood. The patient reported recent problems in relationships with several friends and eating only one meal a day prior to hospitalization due to a desire to lose weight. The patients eating improved over the course of her hospitalization. There is evidence of recent gains and/or stabilization in functioning were achieved while participating in treatment in a structured, protected, and/or enriched service. For dimension 3, the patient has significant co-occurrence of conditions (score 3) considering her history of insomnia and asthma as well as a positive COVID-19 test approximately two weeks prior to admission. Depression can cause insomnia and insomnia can exacerbate depressive symptoms. Medical conditions were present that may have adversely affected, or been adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment was highly stressful (score 4). The provider noted that the patients parents were in the process of divorcing and the patients father moved to a new home. The patient has also experienced the recent loss of several friendships and difficulty with school. The patient reported that high school consumed all of her time and left little time for anything else. The records document serious disruption of family and social milieu. For dimension 4B, the patients recovery environment provided minimal support (score 4) due to lack of supportive friends and family. The patient indicated that she did not want to stay at her fathers house. The patient reported that her mother shared too much information about the divorce. Family or primary caretakers were seriously limited in ability to provide for the patients developmental, material, and emotional needs. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to services. (score 3). The records document that prior treatment includes outpatient psychotherapy. Thus, previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient showed limited engagement in recovery services (score 3). The provider charted that the patient was guarded in terms of disclosing certain factors for suicidal ideation and depression. The patient had an ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 24, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS-CASII, the patients scores of 4 on risk of harm also supports Level 5 medically monitored residence-based services. In addition, the psychiatric hospital inpatient treatment was not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the psychiatric hospital inpatient treatment was not medically necessary for the treatment of this patient.Final 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 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.