Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested reimbursement and prospective authorization and coverage for continued psychiatric residential treatment center (RTC) services (Level 5). 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 RTC services.For dimension 1, the patient has been at significant risk of harm (score 3) due to a history of suicidal ideation and self-harm behaviors. The patient has reportedly attempted to tie a cord around neck on two occasions. The patient also has a history of substance use, and is noted to be impulsive and unpredictable. The records document no active suicidal ideation, but extreme distress and a history of suicidal behavior, as well as indication or report of incidents of acting without thinking. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given considerable difficulties in ability to interact with peers and adults due to emotional-behavioral disturbances. The patient struggles to establish and maintain age-appropriate friendships. There is significant conflict with family members. The patients substance use has led to strained family relationships and difficulties at school. The patient's academic career has been disrupted to multiple treatment placements. There is evidence of serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive behaviors. For dimension 3, the patient significant co-occurrences (score 3) considering psychiatric diagnoses and substance use disorder. The patient reports continued urges to use substances. Substance abuse is present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4) given the deterioration of family relationships and difficulty avoiding substance use. The patient has been in and out of various treatment programs and the patient's older sister is also experiencing serious mental health issues. The records document serious disruption of family and social milieu. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider charted that the patients parents struggle to be aligned in their parenting of the patient. The patients parents describe feeling in crisis due to the patient and older sister because they are both struggling with mental health issues. The patients family or primary caretakers demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient has exhibited poor resiliency and response to services (score 4) since previous treatment has been extensive and has not achieved complete remission of symptoms or optimal control of symptoms. Prior treatment has included outpatient treatment including psychiatric care, an intensive outpatient program, a partial hospital program, a wilderness program, two admissions to RTC, and multiple psychiatric hospitalizations. Overall, previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to interventions. For dimension 6, the patient has shown limited engagement in treatment (score 3). The provider noted that the patient lacks insight and expresses ambivalence around change. The patient has developed an ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 24, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS-CASII, the patients scores of 4 for functional status also support treatment at with Level 5 medically monitored residence-based services level of care. Moreover, the RTC services were and 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, the continued psychiatric RTC services (Level 5) were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.