Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: 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, 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. While the patient denied suicidal ideation and did not have a history of suicide attempts, the records noted a history of potentially lethal self-harming behaviors in the form of severe dietary restriction leading to significant weight loss, loss of consciousness, and severe cardiac compromise, including bradycardia. Her self-harm behaviors had resulted in two hospitalizations for medical stabilization. The patient has repeatedly demonstrated periods of inability to care for herself and maintain her physical safety in a developmentally appropriate way. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to continued dietary restriction and other eating disordered behaviors such as taking small bites, tearing food, eating food in a certain order, and calorie counting. The records noted that the patient required a lot of time to complete meals. She endorsed continued urges to restrict. She was attending school virtually as in-person school attendance has been interrupted by her treatment. Recent gains and stabilization of symptoms have been achieved only while in the structure and containment of the residential  therapeutic milieu. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity, reporting symptoms of orthostatic hypotension such as brief periods of dizziness, palpitations, intermittent chest pain, nausea, weakness, headache, constipation, and bloating. These symptoms were due to her eating disorder and may have contributed to continued eating disordered behaviors. She was also noted to have unstable blood sugars and had not had her menses recently. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment as her sister and two aunts have active eating disorders. The patients mother has struggled with an eating disorder in the past. The patient reported challenges in her relationship with her mother, reporting that her mother did not respect her boundaries. With regard to level of support of the recovery environment, the records support a score of 3 due to the parents willingness to participate in their daughters treatment. The patient does not have outpatient providers, and the records note that her sister also struggled with an eating disorder. 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 has included two separate hospitalizations for severe malnutrition and concomitant cardiac compromise. The patient has a history of relapsing following treatment. Previous treatment has not achieved sustained remission nor optimal control of symptoms. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was engaged in treatment but continued to engage in eating disordered behaviors such as tearing food into small pieces, taking very small bites, and taking a long time to finish meals, and struggled to utilize coping skills to manage these symptoms. Thus, the patient has a total score of 24. The records support a 4 in terms of comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the comorbidity noted, the patient met CALOCUS 5b extended stay criteria. 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, 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.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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.