Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for any or all of the residential treatment center (RTC) level of care services. Findings:  The physician reviewer found that  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.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 self-harm behaviors and suicidal ideation. During the period under review, the patient endorsed some intermittent suicidal ideation and urges to self-harm. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to struggles to complete her activities of daily living without prompting, and difficulty keeping herself organized and following through with age-appropriate parental expectations. Her executive functioning was poor. She struggled with understanding social cues and situations, although she achieved recent gains while participating in treatment. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of depression coupled with two neurodevelopmental disabilities, ADHD and expressive/receptive language disorder. 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 a serious disruption in her friend group, which excluded her. The records note tension in the home due to the patients behavior.  With regard to level of support of the recovery environment, the records support a score of 3 as the patients parents are supportive but her friend group has turned on her and is no longer a source of 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, psychiatric care, and psychotropic medication. The patient has struggled with developmental pressures which have created turmoil and sustained distress as evidenced by her suicidal ideation and continued self-harm behaviors. With regard to treatment acceptance and engagement, the records support a score of 3. The patient has struggled to utilize supports and coping skills and endorsed urges to self-harm during the period under review. 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 a 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 level of care 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.