Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested reimbursement for mental health 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, this patient met the criteria for RTC services.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to passive suicidal ideation at the time of admission. The records noted that the patient was passively waiting to die, not eating, drinking, or sleeping. The patient denied suicidal ideation and did not have a history of suicide attempts, but endorsed urges to self-harm and had a history of self-harm by cutting, most recently one year ago. He endorsed extreme distress, eating insufficient amounts and losing six pounds in the weeks preceding admission. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient was isolating from friends, having stopped attending school in the weeks preceding admission. The patient endorsed significant anxiety around eating and was limiting dietary intake, losing six pounds recently. The patient reported getting stressed about going to sleep and feeling tired all the time. The patient would not go to bed or get out of bed without completing a morning and bedtime routine and was not engaging in any hobbies.  With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of insomnia and poor appetite, leading to poor energy and tiredness, that may adversely affect mood and anxiety symptoms. Conversely, depression and anxiety can adversely affect sleep and appetite. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment, reporting feeling overwhelmed by school, and endorsing guilt and shame. The patient's perfectionism caused them to become extremely upset with mistakes, resulting in shutting down and an inability to continue in schoolwork or studying. The patient's obsessive-compulsive disorder (OCD) behaviors interfered with functioning, and became upset and was unable to sleep or get out of bed when the OCD routine was interrupted. Role expectations appeared to exceed the patients capacity given age, status, and developmental level. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents being described as caring, helpful, and supportive. The patient described a good relationship with siblings. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as prior treatment included outpatient therapy, outpatient psychiatric care, and psychotropic medication without achieving complete remission of or optimal control of symptoms, and developmental pressures and life changes have created periods of turmoil and sustained distress. With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrated adequate participation.Thus, the patient has a total score of 21. The records support a 4 in terms of functional status. With the functional impairment noted, the patient met CALOCUS Level 5 criteria. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the level of care that the patient received at the RTC. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, mental health 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.