Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (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 provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. 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) developmental, medical, substance use and psychiatric comorbidity; (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 did not meet the criteria for the RTC services.For dimension 1, the patient was at some risk of harm (score 2) due to a history of intermittent suicidal ideation without a history of suicide attempts. The patient has a history of self-harm behaviors in the form of cutting on her arms and legs. Throughout her treatment stay, she endorsed suicidal ideation intermittently but denied intention of acting on these thoughts. The patient uses substances irregularly. The records support a past history of fleeting suicidal thoughts with no current ideation, plan, or intention and no significant distress. For dimension 2, the patient demonstrated mild functional impairment (score 2) given the presence of depressive symptoms as evidenced by her report of increased social isolation, low motivation, anhedonia, and decreased energy. Some report of not turning in school work but otherwise, the records do not indicate other functional impairment. There is some evidence of minor failures of function in any of several areas of living school, family, peers. These periodic or momentary failures are time limited. For dimension 3, the patient has minor co-occurrence (score 2) since she has a history of insomnia and migraine headaches in addition to depression, anxiety, and post-traumatic stress disorder (PTSD). There are self-limited medical conditions present that are not immediately threatening or debilitating and have no impact on the presenting condition and are not affected by it. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The patients parents are divorced and live across the street from one another, and the family dynamics are described as strained. The patients father was not described as supportive of the patients mental health struggles. The records support disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3). The patient reported that her mother took her mental health seriously, but her father did not. The patient noted that her older sister understood her issues. The patients father did not participate in her treatment while in RTC. The patients family or primary caretakers demonstrated only partial ability to make necessary changes during treatment. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to services (score 3). Prior treatment has included outpatient psychotherapy and psychiatric services. During her stay in residential treatment, she showed limited response to treatment due to her varying levels of engagement and refusal or inability to utilize skills. 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 showed limited engagement in treatment (score 3) due to struggles with motivation and willingness to learn during her time in RTC. The provider noted that the patient had little insight, she did not always complete DBT therapy homework, and she struggled to utilize any acquired skills. The patient frequently missed or was late for treatment appointment and did not follow the service plan. These findings give the patient a composite score of 18, which is consistent with Level 3 high intensity community based-services. Moreover, the RTC services at issue were not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the RTC services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not 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.