Appeal type: Medical Necessity
Decision: Overturned

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 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 inappropriate sexualized behaviors, physical aggression, property destruction, and threatening behaviors. The patient was impulsive, with poor executive functioning, judgment, and insight. He was noted as requiring structure and supervision to prevent further inappropriate behavior.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to problems in social interactions secondary to autism spectrum disorder. The patients emotional and behavioral dysregulation had resulted in numerous suspensions and expulsions. The patient did not get along with peers and was unable to maintain friendships. He did not tolerate change, overreacted, and was described as rigid and inflexible.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) and autism, neurodevelopmental disorders that adversely affected his ability to regulate his mood. The records noted a history of in utero exposure to substances. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to struggles with role expectations that exceed his capacity/abilities as evidenced by his social difficulties, oppositional and defiant behaviors, and difficulties in the academic setting. The records noted that the patients father reported being a control freak. The patients parents were divorced, with court involvement due to concerns of parental alienation by the patients mother, who was described as deeply depressed. The patients stepmother was noted as being terrified of the patient. With regard to level of support of the recovery environment, the records support a score of 3 as the patients family was supportive, but his mother was noted as struggling with depression and his father with trying to excessively control things. The records noted that the patients mother had a history of struggling with setting limits for the patient. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recover management as prior treatment included outpatient psychotherapy, family therapy, and medication management but had not been successful in relief or optimal control of the patients symptoms. With regard to treatment acceptance and engagement, the records support a score of 3. The patient struggled with engaging in treatment, particularly during the first several months of his treatment stay, and in accepting age-appropriate responsibility, although this improved over time. Thus, the patient has a total score of 25. In this case, the recommended level of care was 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.