Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 17-year-old female. Notes dated 1/24/21 reported that the patient had been home 
for three  months  following  discharge  from  a  wilderness  program.  The  patients  parent  has 
requested reimbursement for mental health inpatient services from 1/24/21 through 7/19/21. 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, this patient met the criteria for mental health 
inpatient services.  With regard to risk of harm, the records support a score of 5. The patient had 
an extreme risk of harm, due to current suicidal ideation with a plan. The patient had a history of 
serious past suicide attempts and during the time period at issue relentlessly engaged in acutely 
self-endangering behaviors including cutting, picking scabs, and using a plastic spoon to harm 
herself, and required restraint from staff not to self-harm. In terms of functional status, the records 
support a score of 4. The documentation noted serious functional impairment due to clear, serious 
deterioration of interpersonal interactions with peers. She had consistent conflict with others, 
including  with  staff  and  with  her  parents,  and  demonstrated  highly  impulsive  behaviors.  
With regard to comorbidity, the records support a score of 4. The patient had major comorbidity, 
due to the presence of multiple psychiatric conditions that clearly impaired functioning, persisted 
in the absence of stressors, and seriously impaired recovery from the presenting condition. These 
included severely depressed mood, chronic suicidal ideation and suicidal behaviors, insomnia, 
severe anxiety, and impulsivity secondary to ADHD. In terms of level of stress of the recovery 
environment, the records support a score of 4. The patient had a highly stressful environment due 
to serious and severe conflict in the home. With regard to level of support of the recovery 
environment, the records support a score of 3 due to the patients family having limited ability to 
respond appropriately to her developmental needs and/or problems. In terms of resiliency and 
treatment history, the records support a score of 5. The patient had negligible resiliency and/or 
response to treatment as past response to treatment was quite minimal, even at high levels of care 
for extended periods of time. The patient had failed two RTC attempts,  PHP, and had also failed 
wilderness therapy. With regard to treatment acceptance and engagement, the records support a 
score of 4. The patient had a difficult and unproductive relationship with clinicians and other care 
providers. The patient did not accept age-appropriate responsibility in her role in the development, 
perpetuation, or consequences of the problem, particularly in her suicidal ideation and self-harm  behaviors.  Thus, the patient has a total score of 29. In this case, the recommended level of care is 
medically managed residence-based services. This is consistent with the level of care that the 
patient received with mental health inpatient services. Therefore, mental health inpatient services 
from 1/24/21 through 7/19/21 were medically necessary for the treatment of this patient.