Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is an 18-year-old male with a past psychiatric history of major depressive disorder, generalized anxiety disorder, attention deficit/hyperactivity disorder, unspecified trauma and stressor-related disorder, and cannabis use disorder.  The patient has requested reimbursement for residential treatment services provided from 7/01/20 through 6/04/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that 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 residential treatment services provided from 7/01/20 through 6/04/21. For dimension 1, the records support a score of 3. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The patient has a history of threatening suicide and has attempted suicide in the past. He has a history of impulsive behaviors. During his stay in residential treatment, he had intermittent suicidal ideation and self-harm thoughts. He did not exhibit any unsafe behaviors during residential treatment. This is most consistent with significant risk of harm.  For dimension 2, the records support a score of 3. This dimension assesses the degree to which a patient is able to fulfill responsibilities within developmental constraints. Prior to admission to residential treatment, the patient was refusing to go to school, using drugs regularly, had engaged in an act of arson, stole his motheras credit card and engaged in property destruction. During the period under review, the patient was attending school and completing schoolwork. He was not using substances, and he was getting along with peers and staff. This is most consistent with moderate functional impairment, as the recent gains/stabilization in functioning have been achieved while participating in a structured and protected treatment environment.  For dimension 3, the records support a score of 3. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient has a history of depression, anxiety, attention deficit/hyperactivity disorder and substance use issues. His psychiatric symptoms, neurodevelopmental symptoms, and substance use clearly impaired his functioning prior to admission. During the period under review, the patient had been abstinent from substances for greater than four months, and his psychiatric symptoms had improved. For recovery environment dimension 4A, the records support a score of 3. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patientas environment appears to be moderately stressful as role expectations appear to exceed the patientas capacity, given his age and developmental level. For recovery environment dimension 4B, the records support a score of 2. This dimension assesses the presence of family and social support to augment the recovery environment. The patientas parents are supportive of the patient and are willing and able to participate in treatment. For dimension 5, the records support a score of 4. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. Previous experience in treatment at a low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. The patient was engaged in outpatient therapy, received psychiatric care including medication management, was hospitalized once on an inpatient psychiatric unit, and spent over three months a therapeutic wilderness program. Records indicate that developmental pressures and life changes have created episodes of turmoil/distress for patient, indicative of poor resiliency. For dimension 6, the records support a score of 2. The child and adolescent sub-dimension assesses ability to form therapeutic relationship within developmental constraints. According to records, the patient engaged constructively and well in treatment. He was open about the reasons for his placement in treatment. These findings give the patient a composite score of 20, which is consistent with Level 4, Medically Monitored Community-Based Services. For this reason, residential treatment services provided from 7/01/20 through 6/04/21 were not medically necessary for the treatment of this patient.