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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for acute psychiatric inpatient services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. Applying the CALOCUS framework, the patient met the criteria for the acute psychiatric inpatient services. The patient was at serious risk of harm to himself and others (score 4) due to a history of aggression toward others and making suicidal threats and gestures. The provider reported that the patient demonstrated poor perspective taking, mood lability and emotional reactivity. The records report that he recently choked a cat while at the RTC program, along with cutting self with scissors in suicide attempt. The patient demonstrated severe functional impairment (score 5) in the social and emotional realms, which resulted in his inability to maintain at home due to severe aggression, suicidal and homicidal threats. In addition, the patient reportedly made suicidal threats while at the RTC level of care prior to transitioning to the acute psychiatric inpatient level of care. While at the hospital, the patient has not exhibited suicidal ideation, homicidal ideation, or severe dysregulation. However, the provider noted that the hospital was highly structured and the patient has appeared to respond to the structure. Moreover, the patient has attempted to engage in safer behaviors with hopes of returning home. The patient has major comorbidities (score 4) given his multiple diagnoses including autism, attention-deficit/hyperactivity disorder (ADHD), and generalized anxiety disorder (GAD). The provider also documented the presence of depressive disorder, dysgraphia, sensory processing disorder, and parent-child relational problem. The patients recovery environment was highly stressful (score 4) as his home environment was concerning for ongoing struggles with his parents including multiple conflicts, severe mood issues, and behavioral dysregulation episodes. The patients recovery environment provided limited support (score 3) as his mother has a history of post-traumatic stress disorder (PTSD) and his father has required rehabilitation services for an alcohol use disorder. The patients parents have been overwhelmed with his behaviors and have been unable to provide adequate support for the patient. The patient was unengaged in treatment (score 5). The records report that the patient had little positive response in various treatment settings such as outpatient therapy and RTC prior to this hospitalization. The patient was incompletely engaged in treatment (score 3) as he showed improved behaviors in an attempt to be discharged to home. The patient continued to have difficulty adhering to expectations, but he was able to remain safe in the highly structured program with substantial supervision and guidance. These findings give the patient a composite score of 28, which is consistent with Level 6 medically managed residence based services. For these reasons, the acute psychiatric inpatient services were medically necessary for 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 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.