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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for (1) inpatient hospitalization and (2) electroconvulsive therapy services (12 treatments).With regard to risk of harm, the records support a score of 5. The patient has an extreme risk of harm, due to a history of suicidal ideation, self-harm, and aggression towards others. During her hospitalization, she has been unable to go more than three days without the use of four-point restraints and no more than one day without self-harm or aggression towards others. In terms of functional status, the records support a score of 5. The documentation noted severe functional impairment as the patient struggles to complete her activities of daily living, including attending to her hygiene. She engages in assaultive behaviors towards others with minimal provocation and appears to have minimal control over her impulses. She requires frequent redirection from staff to maintain appropriate behavior and frequent use of as needed medication, more than once daily. She requires 1:1 staff support for her safety and the safety of others. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity. The patient was exposed to methamphetamine in utero. She has two developmental disorders, attention deficit hyperactivity disorder (ADHD) and autism, in addition to multiple psychiatric disorders.  She has had a 50-pound weight gain over the last year secondary to psychotropic medications and her laboratory testing results indicate that she is suffering from insulin resistance, necessitating the use of metformin. She also suffers from constipation, both of which can cause an increase in aggressive and self-injurious behaviors in those with developmental disabilities. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a moderately stressful environment as her relationships with others are strained and role expectations exceed her capacity, given her numerous behavior problems. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has few, if any, peer supports. The patients parents appear supportive of the patient.  Community resources only partially compensate for the patients unmet emotional needs. In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible resiliency and/or response to treatment as prior treatment has included psychiatric medications, residential treatment, and over seven prior psychiatric hospitalizations. With regard to treatment acceptance and engagement, the records support a score of 4. The patient appears to be minimally engaged in treatment as evidenced by her inability to reflect on her behaviors and their antecedent events, and her continued engagement in self-harm and aggression instead of utilizing coping skills and environmental supports. However, the patient has been compliant with her medication regimen. Thus, the patient has a total score of 29. The records support a 5 in terms of level of risk and of functional status, and a 4 in terms of comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets CALOCUS-CASII Level 6 extended stay criteria and level of care.  In this patients case, inpatient hospitalization level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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, (1) inpatient hospitalization was and is medically necessary for the treatment of this patient. The submitted documentation supports the medical necessity of the requested services. In a systematic review of electroconvulsive therapy in children and adolescents, Dssing and Pagsberg state, Electroconvulsive therapy should be considered in severe, treatment-resistant mood disorders, catatonia, and schizophrenia, especially in older adolescents. The authors further noted findings that patients with autism spectrum disorder and intractable self-injury who were treated with electroconvulsive therapy had a 50% reduction in self-injurious behavior and aggression scores after electroconvulsive therapy. Castaneda-Ramirez and colleagues state, Electroconvulsive therapy is safe and effective for the treatment of mood disorders in child and adolescent populations, and should be considered in severe and treatment-refractory cases. In this case, while the patient does not have a diagnosis of mood disorder, the  records indicate that she suffers from mood instability as evidenced by her repeated episodes of agitation, self-injury, and aggression towards others, necessitating ten to 16 physical restraint episodes weekly over the last three weeks. Multiple psychiatric hospitalizations and a lengthy stay in residential treatment coupled with multiple medication trials have not been successful in ameliorating the patients symptoms. In this patients case, electroconvulsive therapy is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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, (2) electroconvulsive therapy services (12 treatments) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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.