Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for intensive in-home family treatment (IIFT) program for therapy five hours per week. 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 meets criteria for medically monitored community-based treatment services and meets the criteria for IIFT program for therapy five hours per week. For dimension 1, the patient has been at significant risk of harm (score 3). The patient reports having intrusive thoughts about suicide. There is no reported history of suicide attempts. The patient has issues with elopement. The records support an indication or report of incidents of acting without thinking, such as running away. For dimension 2, the patient has demonstrated moderate functional impairment (score 3). The records indicate that the patient became obsessed with a high school teacher and the patients relationship with family members has deteriorated. There is evidence of conflicted, withdrawn, or otherwise troubled relationships with peers, adults and family, but without episodes of physical aggression. For dimension 3, the patient has minor co-occurrences of conditions (score 2) since there is documentation of seasonal allergies and insomnia. Depression can cause insomnia and, insomnia can exacerbate depression and mood dysregulation. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) due to recent deterioration of family relationships and the patients allegations of abuse. The records document disruption of family and social milieu. For dimension 4B, the patients recovery environment provides limited support (score 3) since the patients parents appear to be supportive, but community resources only partially compensate for the patients emotional needs. Overall, the records indicate that community resources only partially compensate for the patients unmet material or emotional needs and/or the patient has limited or inconsistent access to network. For dimension 5, the patient has shown moderate or equivocal resiliency and response to services (score 3). The provider noted that prior treatment has included outpatient psychotherapy and psychiatric care including medication management. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has shown limited engagement in treatment (score 3) since the provider has described the patient as being resistant to participating in care and resistant to discussing problems. The patient has developed ambivalent, avoidant, or distrustful relationships with clinicians and other care providers. These findings give the patient a composite score of 20, which is consistent with Level 4 medically monitored community-based services. Although the patients IIFT was Level 3, the requested five hours per week is appropriate since Level 4 services generally average five to 16 hours per week according to CALOCUS-CASII. Moreover, the requested IIFT program is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the requested IIFT program for therapy five hours per week is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.