Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for psychiatric 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 did not meet 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 with a plan. The patient engaged in daily self-harm by scratching to the point of bleeding on the arms, hands, and fingers. On admission to the RTC, the patient denied suicidal ideation but endorsed ongoing desire to self-harm. The records document an ability for the patient and their family to carry out a safety plan. The patient expressed some reason to not act on their suicidal ideation. In sum, although there was a history of suicidal ideation, the patient did not have current suicidal ideation during the timeframe in dispute.For dimension 2, the patient demonstrated moderate functional impairment (score 3) since they did not engage in their usual hobbies and reported sleeping a lot during the day. The patient also endorsed difficulty focusing. The patient did not attend school since September 2021 due to their need for mental health treatment. The patients school behavior deteriorated to the point of the patient has some school disciplinary action and is at risk for placement in an alternative school program or repeating their grade. Absenteeism may be sporadic. For dimension 3, the patient has significant co-occurrence (score 3) given their history of exercise induced asthma and early insomnia. The patients treatment for asthma can exacerbate anxiety symptoms. Insomnia can exacerbate depressive and anxiety symptoms and conversely, depression and anxiety can contribute to ongoing insomnia. Medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The records document conflict between the patient and their parents due to the patients ongoing self-harm behaviors. There is also disagreement between the patient and their parents about medical transitioning from female to male. The patient described that their parents have high expectations. There is evidence of role expectations that exceed the patients capacity given age, status, and developmental level. For dimension 4B, the patients recovery environment was supportive (score 2) since the patient described a close and supportive relationship with both parents who were supportive of the patient. The patient also described having friends who were supportive. The patients family were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient exhibited poor resiliency and response to services (score 4). The provider noted that prior treatment has included outpatient psychotherapy, psychotropic medication, a partial hospital program, RTC, and one previous inpatient psychiatric hospitalization. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to interventions. For dimension 6, the patient showed limited engagement in services (score 3) due to reluctance to commit to change. At times the patient was noted to exhibit poor insight and reluctance to self-disclose. The patient acknowledged existence of problem but resisted accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem.These findings give the patient a composite score of 21, which is consistent with Level 4 medically monitored community-based services. Moreover, the RTC services were not in accordance with the generally accepted standards of mental health and substance use disorder care, and not clinically appropriate in terms of type, frequency, extent, site, and duration. All told, the psychiatric RTC services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.