Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. 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 met the criteria for RTC services.For dimension 1, the patient was at serious risk of harm (score 4) due to denial of suicidal ideation and lack of a history of suicidal ideation or suicide attempts. However, the patient does have a history of engaging in self-harming behaviors in the form of severe dietary restriction leading to significant weight loss with resulting medical sequelae including severe cardiac compromise as evidenced by bradycardia, hypotension, and an abnormal electrocardiography (EKG). These self-harm behaviors have resulted in two hospitalizations for medical stabilization. The patient has repeatedly demonstrated clear and persistent inability, given developmental age, to maintain physical safety. For dimension 2, the patient exhibited serious functional impairment (score 4) as evidenced by her inability to maintain proper nutrition and stable weight. The patient continued to engage in dietary restriction despite significant support and intervention. The records document serious disturbances in physical function. For dimension 3, the patient has major co-occurrence (score 4) considering her eating disorder and obsessive compulsive disorder. The patient has been hospitalized twice for medical instability due to anorexia. The patient has a history of amenorrhea, abnormal liver functioning, low vitamin D, leukopenia, and had an abnormal EKG during the period under review. The patients eating disorder placed her at risk of malnutrition, vital sign instability, electrolyte disturbances, and cardiac abnormalities. The records document that medical conditions were present or had a high likelihood of developing that may have required intensive, although not constant, medical monitoring. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patient and her parents viewed relapse experiences as failures, which caused the patient significant distress. The patient also showed distress when complying with her meal plan due to fear of weight gain. The patients home environment is noted to be a high pressure environment. The patient is noted to have a conflicted relationship with her parents who are described as overinvolved. Role expectations appear to exceed the patients capacity given her age, status, and developmental level. For dimension 4B, the patients recovery environment provided limited support (score 3). Although the patients parents were supportive, the provider charted that the patients parents were unable to logistically support all of her meals. The patients parents demonstrated only partial ability to make changes during treatment. For dimension 5, the patient demonstrated poor resiliency and poor response to services (score 4) since prior treatment has included outpatient treatment consisting of individual and family therapy as well as dietetic support, a partial hospitalization program, and two medical hospitalizations due to medical instability. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient showed limited engagement in services (score 3). The records document that the patients participation was limited as evidenced by her inability to comply with treatment expectations and gain weight as expected in a lower level of care. The patient also minimized and rationalized her eating disordered behaviors. These findings give the patient a composite score of 25 which is consistent with Level 5 medically monitored residence-based services. In addition, per CALOCUS-CASII, the patients scores of 4 for risk of harm, functional status, and co-occurrence also supports treatment at Level 5 medically monitored residence-based services level of care. Furthermore, the RTC services were 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, the RTC services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be 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.