Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for wilderness therapy services and/or 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 did not meet the criteria for wilderness therapy services and RTC services.For dimension 1, the patient was at significant risk of harm (score 3) due to verbal and physical aggression towards family members. The patient denied suicidal and homicidal ideation. There is indication or report of incidents of acting without thinking or physically aggressive actions that endanger self or others. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given the patients struggles with online schooling and personal hygiene. The provider noted that prior to admission to the wilderness program, the patient demonstrated aggressive and explosive behaviors at home and had difficulties with online schooling. In addition, he was not attending to self-care such bathing or brushing his teeth. The records document self-care/hygiene deteriorated below usual or expected standards on a frequent basis. For dimension 3, the patient has significant co-occurrence of conditions (score 3) as evidenced by his neurodevelopmental disorders including autism and attention-deficit/hyperactivity disorder (ADHD), as well as psychiatric disorders disruptive mood dysregulation disorder and depression. Developmental disability was present that may adversely affect the presenting condition and may have required significant augmentation or alteration in treatment for the presenting condition or adversely affects the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) considering the conflict between the patient and his parents. The records document that the patient had role expectations that exceeded the patients capacity given his age, status, and developmental level. For dimension 4B, the patients recovery environment provided limited support (score 3). The patients parents appeared supportive of the patient as evidenced by their engagement in treatment. However, community resources only partially compensated for unmet emotional needs. For dimension 5, the patient exhibited poor resiliency and response to services (score 4). The provider noted that prior treatment has included outpatient psychotherapy, psychiatric medications, and a day treatment program. The patient has demonstrated frequent evidence of innate vulnerability under stress and difficulty resuming progress toward expected developmental level. In addition, previous treatment has not achieved remission of symptoms or optimum control of symptoms even with intensive or repeated exposure to interventions. For dimension 6, the patient showed adequate engagement in treatment (score 2) due to the patients participation in therapeutic interventions. Overall, the patient was able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 21, which is consistent with Level 4 medically monitored community-based services. Moreover, the wilderness services and 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. For these reasons, the wilderness therapy services, and RTC services were not medically necessary for the 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.