Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC). 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, due to a history of suicidal ideation with a plan, without suicide attempts, and a history of self-harm and anger dyscontrol. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient reported that she had stopped going to school and doing any academic work. The records noted failure in a variety of school settings, along with trouble getting out of bed and showering daily. The patient had a conflictual relationship with her father and intermittent conflict with her mother. She had lost friends due to her mental health issues and did not have any local friends. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of attention deficit hyperactivity disorder (ADHD), a neurodevelopmental disorder that played a role in the patients lack of academic achievement and difficulty managing her anger and mood. The patient had symptoms of depression and anxiety, that could contribute to worsening focus and concentration, thereby exacerbating ADHD symptoms. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment as she did not have a close relationship with her father, reporting that he did not know or understand her. The patient reported arguing with her mother over her mental health, and that her parents had a conflictual relationship and often argued. The patients grandmother passed away one month prior to the patients RTC admission. The patient was struggling in school. With regard to level of support of the recovery environment, the records support a score of 3 as the patient reported that her online friends were supportive but reported losing friends due to her mental illness. She did not have any local friends, did not view her father as supportive, and argued with her mother over her mental health challenges. 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 included outpatient psychotherapy, dialectical behavior therapy (DBT), a day treatment program, intensive outpatient program (IOP), and partial hospitalization program (PHP). The patient had been in a variety of school settings to support her academic success, without significant progress. She demonstrated frequent evidence of innate vulnerability under stress and difficulty resuming progress towards an expected developmental level. With regard to treatment acceptance and engagement, the records support a score of 3. The patient participated in group and individual therapy. However, she was unwilling to consider medication for her ADHD despite recommendation by psychiatrist and was not attending school. Thus, the patient has a total score of 23. In this case, the recommended level of care is medically monitored residence-based services. 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.