Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 17-year-old female with a past psychiatric history of major depressive disorder, 
recurrent, moderate, attention deficit hyperactivity disorder, and generalized anxiety disorder. The 
patients parent has requested reimbursement for residential treatment center services provided 
from 9/21/21 through 10/20/21. 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, the patient did 
not meet the criteria for residential treatment center services provided from 9/21/21 through 
10/20/21. For dimension 1, risk of harm, 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 had 
intermittent suicidal thoughts over the past year. She has never attempted suicide. She has self-
harmed twice in the previous year and engaged in minor self-harm during her stay in residential 
treatment center. The patient denied active suicidal ideation throughout her stay in the residential 
treatment center, although she did endorse passive suicidal ideation shortly before discharge.  For 
dimension 2, functional status, the records support a score of 3. This dimension assesses the degree 
to which a person is able to fulfill responsibilities within developmental constraints. The patient 
struggled to do things secondary to her anxiety. She was not waking up until noon and wore the 
same clothes for several days in a row. She was verbally aggressive towards her parents. For 
dimension 3, co-occurring developmental, medical, substance use and psychiatric conditions, 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 mild co-occurrence as evidenced by a neurodevelopmental disorder 
(attention deficit/hyperactivity disorder) in addition to her psychiatric disorders of depression and 
anxiety. The patient also struggles with insomnia, which may be secondary to anxiety and 
depression but can also exacerbate these conditions. For dimension 4A, level of stress in the 
recovery environment, the records support a score of 3. This dimension assesses the stressors in 
the environment, social circumstances, and interpersonal relationships. The patient has a history 
of being bullied. She struggles academically. Her mother had cancer two years ago, and the patient 
is concerned about the cancer returning. For dimension 4B, level of support of the recovery 
environment, the records support a score of 3. This dimension assesses the presence of family and 
social support to augment the recovery environment. Her parents appear supportive of the patient.  
For dimension 5, resiliency and response to services, the records support a score of 2. This 
dimension assesses how past experiences with treatment and recovery might indicate how the 
patient might respond in the future. Prior treatment has included several years of outpatient  psychiatric  treatment,  including  multiple  psychotropic  medication  trials.  For  dimension  6, 
engagement of the patient, the records support a score of 3. The child and adolescent sub-
dimension assesses the patients ability to form therapeutic relationship within developmental 
constraints. This patient was adequately engaged throughout treatment but struggled to utilize 
coping skills at times as evidenced by her engagement in self-harm while in the residential 
treatment center. These findings give the patient a composite score of 20, which is consistent with 
Level 4 Medically Monitored Community Based Services. Therefore, residential treatment center 
services provided from 9/21/21 through 10/20/21 were not medically necessary for the treatment 
of this patient.