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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly appointments for mental health therapy services with a trauma care specialist. 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 meets the criteria for low intensity community-based services which can take many forms and can range from one hour every four weeks to up to two hours per week. Therefore, weekly appointments for mental health therapy services with a trauma care specialist is medically necessary for the treatment of the patients mental health disorder.For dimension 1, the patient is at some risk of harm (score 2) due to suicidal ideation without a plan, which required treatment in the emergency department in February 2022. The patients parents reported that the patient has ongoing suicidal ideation, but at her most recent visit with the provider on 5/12/22, the patient denied suicidal ideation. The patient does not have a reported history of suicide attempts, but she has scratched herself in the past, and she is noted to have a history of impulse control difficulties. There is documentation of mild suicidal ideation with no intent or conscious plan and with no past history. For dimension 2, the patient has demonstrated mild functional impairment (score 2) given her struggles with reading comprehension and completing projects. The patient has a part-time job which she enjoys, and she is engaging in her hobbies such as guitar playing and performing. The patient experienced some decline in her grades, but her grades are currently improving. There is some evidence of minor failures of function in any of several areas of living including school, family, and/or peers. These periodic or momentary failures are time limited. For dimension 3, the patient has significant co-occurrence (score 3) given the presence of autism and ADHD, which are two neurodevelopmental disorders, in addition to anxiety and a mood disorder. The patient also has comorbid asthma and joint pain. Anxiety and panic can often co-occur with asthma and there may be an overlap of symptoms. Furthermore, anxiety can exacerbate asthma symptoms such as shortness of breath. The records document that medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The provider noted that the patient has some struggles in school with reading comprehension and completing projects. The patient identifies that school can be a source of stress. The patients parents are divorced. The records support significant transition requiring adjustment, such as change in household members, or new school or teacher. For dimension 4B, the patients recovery environment is supportive (score 2) due to her fathers and stepmothers involvement in her treatment. The patient reports adequate social support. The patients family/primary caretakers are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited moderate or equivocal resiliency and/or response to services (score 3) since treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. Prior treatment has included outpatient therapy, psychiatric care, and psychotropic medications. The records indicate that 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 has shown adequate engagement in treatment (score 2). The provider charted that the patient is engaged in treatment, but she also demonstrates intermittent irritability and disinterest during therapy sessions. The patient has been passively cooperating in treatment planning and services. These findings give the patient a composite score of 16, which is consistent with Level 2 low intensity community-based services. Per CALOCUS-CASII, treatment intensity of clinical services at Level 2 ranges from one hour every four weeks, up to two hours per week. However, the medical records do not support a clinical indication for the services of a trauma care specialist. The provider noted a diagnosis of PTSD on one date of service without signs or symptoms to support this diagnosis. In the absence of a trauma-related mental health diagnosis, the services of a trauma specialist are not appropriate. Moreover, the requested weekly appointments for mental health therapy services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, weekly appointments for mental health therapy services are medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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.