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 180 days of dual diagnosis residential treatment center (RTC) at a facility that offers multi-modal program including cognitive behavior therapy (CBT), dialectical behavior therapy (DBT), eye movement desensitization and reprocessing (EMDR), EAGALA, solution-focused therapy, motivational interviewing, experienced-based therapy, and group therapy that offers anger management, specific trauma-focused groups, substance abuse programming, including 12-step and drug prevention strategies. 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 meets the criteria for 180 days of treatment at a dual diagnosis RTC at a facility that offers the requested multi-modal program.For dimension 1, the patient has been at serious risk of harm (score 4) due to a history of suicidal ideation, self-harm, and at least two suicide attempts. The patient also endorses use of substances and alcohol. He has a history of impulsive behaviors and exhibits poor insight and judgment. His behaviors have physically harmed others such as when he put THC powder on family members food, causing them to get sick. The records support indication or report of significant impulsivity and/or physical or sexual aggression, with poor judgment and insight, and that is/are significantly endangering to self or others. For dimension 2, the patient has demonstrated serious functional impairment (score 4) as evidenced by his disrupted interactions with family members, staff, and peers as well as impulsive behaviors. The provider noted that the patient has few friends, and his behavioral issues have resulted in legal consequences. Despite having an individual education plan (IEP), the patient is failing in school, and he has been suspended from school in the past. The patient has been unable to perform adequately even in a specialized school setting due to disruptive behavior, inattentiveness or frequent unexcused absence from school. The patient has multiple academic failures. For dimension 3, the patient has significant co-occurrence (score 3) considering the patients psychiatric, neurodevelopmental, and substance use disorders. The records also document a history of insomnia and asthma. The records document medical conditions requiring significant medical monitoring and substance abuse, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4) given his highly conflictual relationship with his mother and brother. The patient has expressed his intention to continue to use substances until age 17. The patient is failing in school and has legal charges pending. There is documentation of difficulty avoiding exposure to substance use and its effects. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider noted that the patients mother appears supportive, but she struggles to effectively parent the patient. The patients father is not involved in his life. The patients family has limited ability to respond appropriately to the patients developmental needs and/or problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient has exhibited poor resiliency and response to services (score 4) since prior treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to interventions. Previous treatment has included outpatient therapy, multiple psychotropic medications, a partial hospital program, multiple RTC placements, and at least one inpatient psychiatric hospitalization. For dimension 6, the patient has shown minimal engagement in services (score 4) due to variability in participation with treatment. Although the patient has attended groups, he struggled to utilize coping skills taught during those groups. The provider described the patient as disrespectful and oppositional with staff. The patient has not been compliant with taking prescribed medications. This supports a difficult and unproductive relationship with clinicians and other care providers, in addition to actively, frequently disrupts assessment and services. These findings give the patient a composite score of 26, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS-CASII, the patients scores of 4 for risk of harm and functional status also supports treatment with Level 5 medically monitored residence-based services. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. For these reasons, the requested 180 days of dual diagnosis RTC at a facility that offers multi-modal program including CBT, DBT, EMDR, EAGALA, solution-focused therapy, motivational interviewing, experienced-based therapy, and group therapy that offers anger management, specific trauma-focused groups, substance abuse programming, including 12-step and drug prevention strategies is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.