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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for Level 5 medically monitored residence-based services (residential treatment for mental health). 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 and does not meet the criteria for RTC services.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of threatening suicide, aggression toward her mother, dietary restrictions and excessive exercise. The records did not note a history of suicide attempts. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patient engaging in dietary restriction and excessive exercise. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of an eating disorder, anxiety, obsessive compulsive disorder (OCD), and learning disorder. While her body mass index is within the normal range, her eating disorder places her at risk of malnutrition, vital sign instability, electrolyte disturbances, and cardiac abnormalities, among other things.  Anxiety and OCD symptoms may exacerbate eating disorder behaviors and conversely, malnutrition and eating disordered behaviors can exacerbate anxiety and OCD. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to a strained relationship with her parents, particularly her mother. School is challenging for her because of her learning disorder. With regard to level of support of the recovery environment, the records support a score of 2 due as the parents appear supportive of patient.  In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as prior treatment has included psychiatric medication, several residential treatment programs, and inpatient hospitalization. With regard to treatment acceptance and engagement, the records support a score of 2. The patient appears adequately engaged in treatment. 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 was and is receiving 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, Level 5 medically monitored residence-based services (residential treatment for mental health) were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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.