Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that 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 met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4) due to a history of suicidal ideation and self-harm behaviors. The patient reported multiple previous suicide attempts, which he characterized as impulsive. The patient also has a history of significant substance use. During the period under review, the patient endorsed suicidal ideation and engaged in self-harm behaviors. The provider described the patient as impulsive with poor emotion regulation. The provider noted that the patients self-harm and suicidal threats have required police intervention in the past. The records support current suicidal ideation with either clear, expressed intentions and/or a past history of carrying out such behavior. The patient expressed ambivalence about carrying out the safety plan. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given his inability to complete his hygiene routine and disrupted interactions with others. The patient also reported having no friends. There is evidence of conflicted, withdrawn, or otherwise troubled relationships with peers, adults, and family, but without episodes of physical aggression, as well as self-care/hygiene deteriorated below usual or expected standards on a frequent basis. For dimension 3, the patient had major co-occurrence (score 4) due to significant comorbidity with diagnoses including depression, anxiety, and substance use disorder. His longest period of abstinence has been five weeks. During the period under review, the patient exhibited psychiatric symptoms that clearly impaired his functioning, and persisted in the absence of stressors, and seriously impaired recovery from the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) considering the role expectations that exceeded the patients capacity given age, status, and developmental level. The patient reported having easy access to substances and a conflictual relationship with his mother. The police have been called to the patients home multiple times because of the patients self-harm and threats to commit suicide. For dimension 4B, the patients recovery environment provided limited support (score 3). The records document that the patients family struggled to break maladaptive ways of engaging with one another. Overall, the patients family demonstrated only partial ability to make necessary changes during treatment. For dimension 5, the patient has shown poor resiliency and response to services (score 4). Prior treatment has included outpatient psychotherapy, psychiatric care and various psychotropic medications, two intensive outpatient programs, and several psychiatric hospitalizations. 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 exhibited limited engagement in services (score 3). The provider noted that although the patient engaged in treatment during the period under review, he struggled with accountability and rigid thinking. The provider charted that the patient was reluctant to demonstrate authenticity. The patient acknowledged the existence of a problem but resisted accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. 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 and co-occurrence also support treatment with Level 5 medically monitored residence-based services level of care. Moreover, the RTC services were 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 RTC services were medically necessary for 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 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.