Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent 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 significant risk of harm (score 3) due to a history of suicidal ideation, but the patient denied suicidal ideation during the period under review. The patient does not have a reported history of suicide attempts. However, the patient has significant substance use issues which he returned to immediately following discharge from RTC three weeks prior to this admission. The patient exhibited excessive use of alcohol and other drugs resulting in potentially harmful behaviors. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given the patients history of cannabis use at least twice during this RTC admission, which indicated that he experienced difficulty abstaining from substance use. The patients recent gains in functioning were achieved while participating in the highly structured and contained environment of the RTC. For dimension 3, the patient has significant co-occurrence (score 3) since he has a history of at least two substance use disorders. The patient tested positive for tetrahydrocannabidiol (THC) twice during the current RTC admission. The patients recent substance use that had significant impact on the presenting condition was arrested due to the patients participation in the highly structured and protected setting of RTC. For dimension 4A, the patients recovery environment was highly stressful (score 4). The records document that the patients mother struggles with alcohol dependence, recently relapsed, and was away as a result. The patient expressed concern about his mothers drinking patterns and how it affects him. The patient does not have contact with his biological father due to fathers substance use and he struggles to be open with his stepfather. The records document serious disruption of family or social milieu due to separation of parent and patient. For dimension 4B, the patients recovery environment provided limited support (score 3) considering the patients history of addiction which prevented him from participating in treatment. The patients grandmother and stepfather participated and were supportive, but the patients stepfather struggled with effective communication with patient. The patients family had 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 exhibited poor resiliency and response to services (score 4). The provider noted that prior treatment has included RTC and PHP. The patient was unable to maintain sobriety following his discharge from RTC. Per the records, attempts to maintain whatever gains that were attained in intensive treatment have limited success, even for limited time periods or in structured settings. For dimension 6, the patient showed limited engagement in treatment (score 3). The provider noted that the patient was participatory in groups and therapy but also demonstrated a pattern of shutting down and withdrawing. The provider noted that the patient avoided conflict and struggled to communicate with his stepfather in family therapy. The records document an ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 23 which is consistent with Level 5 medically monitored residence-based services. Moreover, 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. Given these findings, the RTC services were medically necessary for 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.