Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that 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 met the criteria for RTC services.For dimension 1, the patient has been at serious risk of harm (score 4) due to multiple previous suicide attempts, one via overdose which resulted in an intensive care unit (ICU) admission. The patient has a history of suicidal ideation and self-harm behaviors. The patient endorses a history of homicidal ideation towards parents. During this RTC admission, the patient engaged in self-harm after becoming angry. The patient is described as impulsive and has a history of eloping from home. The records document current suicidal ideation with either clear, expressed intentions and/or a past history of carrying out such behavior. The patient has expressed ambivalence about carrying out the safety plan and/or the patients familys ability to carry out the safety plan is compromised. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) as evidenced by the struggles to maintain appropriate boundaries with peers, difficulty being respectful to RTC staff, and complying with the RTC rules. The patient has shown difficulty regulating emotions and has a highly conflictual relationship with their parents. There is evidence of conflicted, withdrawn, or otherwise troubled in relationships with peers, adults, and family, but without episodes of physical aggression. For dimension 3, the patient has significant co-occurrence (score 3) given their diagnoses of depression, anxiety, and substance use disorders. The patient endorses daily cannabis and nicotine use in addition to alcohol. The records report problems with insomnia. The patient is transgender and takes testosterone. The records indicate that medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment has been highly stressful (score 4) due to family discord, a history of being bullied, and struggles at school. The patient has a lot of anger towards their mother and feels that their parents do not trust them. There is documentation of serious disruption of family and social milieu. For dimension 4B, the patients recovery environment has provided limited support (score 3). The provider noted that the patient has been unable to identify their social support system. The patients parents appear supportive, but the family struggles to break maladaptive ways of engaging with one another. The patients family or primary caretakers demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient has exhibited poor resiliency and response to services (score 4). The records report that prior treatment has included outpatient psychotherapy, psychiatric care and psychotropic medication, and at least one psychiatric hospitalization. The patient has also required treatment in the emergency department several times for panic attacks. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to interventions. For dimension 6, the patient has shown limited engagement (score 3). The records indicate that the patient has required redirection for poor physical boundaries with peers. The patient has also struggled to comply with the RTC rules and has been disrespectful to the providers. The patient was noted to have walked out of a family session. The patient has an ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 24, which is consistent with Level 5 medically monitored residence-based services. Per CALOCUS-CASII, the patients scores of 4 for risk of harm also supports treatment with Level 5 medically monitored residence-based services level of care. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) 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 psychiatric RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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 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.