Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the acute inpatient psychiatric level of care services received. between two separate ranges of dates of service.  Findings:  The physician reviewer found that the patient was admitted to the inpatient unit due to anxiety issues and behavioral problems. It is noted that prior to each of the disputed inpatient stays, the patient had been treated in an acute inpatient psychiatric level of care. The records demonstrate that when the patient was eventually admitted to the inpatient stays, he was not experiencing acute psychiatric symptoms. During the prior stay, the patient presented with recent homicidal ideation; however, this homicidal ideation was not present at the time of admission and did not reoccur at any time during the patients stay. The primary reason for treatment in the inpatient settings was due to anxiety issues as well as the patients struggles with religion and spirituality. The patient was noted to be cooperative in therapy and often discussed his anxiety issues and was able to problem solve regarding his issues. The progress notes do not indicate any aggression towards any peers or staff. The progress notes do not document any self-harm behaviors. The progress notes do not indicate any active suicidal or homicidal ideation. The progress notes do not reflect any signs or symptoms of psychosis. The progress notes do not indicate any treatment refusal or medication refusal. The progress notes do not document any serious problems with activities of daily living or serious or severe adverse reactions to medications. The patient was undergoing individual therapy while in the inpatient facility. Progress notes indicate this therapy was DBT, CBT, and family therapy. However, these services could have safely and effectively taken place in a less restrictive setting due to the fact that the patient was very cooperative in treatment and was not exhibiting any dangerous behaviors or psychosis. Studies found Randomized clinical trials have established the efficacy of individual CBT to treat separation anxiety disorder, social anxiety disorder, and generalized anxiety disorder in children as young as seven years. The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Based on the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient was a candidate for intensive outpatient program (IOP) services during the periods under review. According to the CALOCUS, the patient had some risk of harm (2) due to a history of suicidal ideation without current active suicidal ideation, a mild to moderate functional status (2) given the patients issues with role performance due to psychiatric symptoms, and overall medical stability and no substance abuse issues (0), the patient had no medical, addictive or psychiatric co-morbidity. The patients recovery environment, living environment and environmental support are stable (2), with a family that is supportive of his treatment needs, engaged in his treatment, and actively working with staff and the patient. The patient has a score of (3) for resiliency and treatment history, which is equivocal, given the minimal to moderate treatment response judged by repeated hospitalizations, and is constructive, with a score of (2) for acceptance and engagement due to good patient participation and a score of (2) for parent acceptance and engagement. This gives the patients presentation a composite score of 15. A score of 15 correlates with a treatment intensity level of three which correlates with IOP services. This score is judged by the acuity of the patients symptoms and environment during the periods under dispute, as of the date of denied health plan authorization. According to the CALOCUS, the requested level of care criteria were not met. All told, the acute inpatient psychiatric level of care services provided and acute inpatient psychiatric level of care services provided during the dates of service in question were not medically necessary for treatment of this patients behavioral health issues. 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 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.