Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient 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 4. The patient had a serious risk of harm, due to a remote history of self-harm behaviors, and continued dietary restriction and eating disordered behaviors and the associated high mortality rate of eating disorders. Transgender individuals are at far greater risk of dying by suicide than their cis-gender counterparts. The records noted a lack of insight.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to an inability to properly nourish themself. The records noted that despite extensive support while in treatment, the patient failed to gain or maintain weight. He engaged in other eating disordered behaviors such as hiding food, water loading, and refusing to eat processed foods. The patient had not attended in-person school for years and had become increasingly isolative. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity, due to the presence of diagnoses including obsessive compulsive disorder (OCD), eating disorder that requires close monitoring, gender dysphoria, and sleep disorder. Other medical sequalae of eating disorders include cardiac arrhythmias and hypotension. The patient's OCD symptoms can contribute to the dietary restriction and other eating disordered behaviors, leading to worsening physical consequences, and issues with sleep may exacerbate mental health symptoms. 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 the sister also had an eating disorder and is in recovery. The patients parents were divorced, and the records noted family conflict. With regard to level of support of the recovery environment, the records support a score of 4 as the records noted that the patients parents did not appear to know how best to support the patient, and the records noted family conflict and that the patient fought with the father during family sessions. The patient did not endorse peer support. 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 outpatient psychotherapy for the last six years, psychiatric care, and one previous eating disorder treatment program. With regard to treatment acceptance and engagement, the records support a score of 3. The patient attempted to manipulate weight by hiding items in clothing. The patient was noted as struggling to stay present and participate, and as being shut down in speaking about own personal experience.Thus, the patient had a total score of 27. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care was medically monitored residence-based services. With the elevated risk of harm, functional status, and comorbidity noted, the patient met CALOCUS 5b extended stay criteria. This was 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.