Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that 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 did not meet the criteria for RTC services. For dimension 1, the patient was at some risk of harm (score 2) due to denial of suicidal ideation, and no reported history of suicide attempts or self-harm behaviors. The patient has a history of manic episodes during which the patient becomes so anxious that the patient cannot contain themselves for about three hours. The records document infrequent, brief lapses in the ability to care for self and use environment for safety. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given struggles with anxiety and depression which caused low energy, amotivation, insomnia, and low mood. The patient described experiencing panic attacks and overwhelming anxiety. The patients grades declined, and described social life being affected by mental illness with loss of friends. There is evidence of conflicted, withdrawn, or otherwise troubled relationships with peers, adults, and/or family, but without episodes of aggression. For dimension 3, the patient has minor co-occurrence (score 3) due to struggles with insomnia for which the patient takes medication. Depression and anxiety can cause insomnia and conversely, insomnia can exacerbate depression and anxiety. The patient also reported frequent opioid use since the age of 16 with last use in October 2021. The records document that 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) due to pressure and anxiety felt about school. The patients biological father died about five years ago and the patient states that his death remains unprocessed. The patients grandfather also died within the past year. The patient also has a history of being bullied. The records support disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3). The patient described the family as close and supportive, but also indicated that the mother puts pressure on the patient with regards to school. The patients family or primary caretakers demonstrated only partial ability to make necessary changes during treatment. For dimension 5, the patient has demonstrated poor resiliency and response to services (score 4). Prior treatment has included an IOP, one psychiatric hospitalization, several visits to the emergency department due to panic attacks, and a PHP. The patients symptomatology has persisted despite multiple treatment attempts at various levels of care. The records establish that 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 adequate engagement in services (score 2). The provider noted that the patient participated in group, individual, and family therapies. The patient passively cooperates in treatment planning and services. These findings give the patient a composite score of 20, which is consistent with Level 4 medically monitored community-based services: intensive integrated services without 24-hour psychiatric monitoring. Moreover, the RTC services were not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. All told, the 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.