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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for psychiatric acute inpatient services. Findings:  The physician reviewer found that 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. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient met the criteria for psychiatric acute inpatient services. For dimension 1, the patient was at extreme risk of harm (score 5) due to current suicidal or homicidal behavior or such intentions with a plan and available means to carry out this behavior without expressed ambivalence or significant barriers to doing so, and a history of serious past attempts that are not of a chronic, impulsive, or consistent nature. In this case, the patient planned and started to execute two separate suicide attempts in the past two months and continued to report daily suicidal ideation throughout her hospital stay. She struggled to manage her suicidal ideation. For dimension 2, the patient exhibited serious functional impairment (score 4) with significant withdrawal and avoidance of almost all social interaction and academic difficulties. The patient showed a lack of communication with her parents and she recently received failing grades. (sub b)For dimension 3, the patient has no reported no comorbidities (score 1). The records document no history of substance use, developmental disabilities, or medical problems. For dimension 4A, the patients recovery environment was mildly stressful (score 2) considering her disruptions to school, social and leisure activities caused by the pandemic. There was disruption of family and social milieu. For dimension 4B, the patients recovery environment was supportive (score 2) given her parents active participation in treatment. Family caretakers were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient demonstrated moderate or equivocal resiliency and response to treatment (score 3) since previous experience in treatment at low level of intensity was not successful in relief of symptoms or optimal control of symptoms. In this case, outpatient psychotherapy at school and through an independent provider did not prevent the patients recent decline in mood and functioning. Also, the patient did not initially respond to inpatient treatment. For dimension 6, the patient was constructive in treatment (score 2). The provider noted that the patient was an active participant is group as well as individual therapy. The patient was able to develop a trusting, positive relationship with clinicians and other care providers. This gives the patient a composite score of 19, which is consistent with high intensity community-based services. Per CALOCUS, the patients score of 5 on risk of harm supports medically managed residence-based services. The patient demonstrated continued extreme risk of harm during this period. Through her discharge, the patient continued to report suicidal thoughts with plan and thoughts of self-harm, with limited coping skills and ability to manage these thoughts. For these reasons, the psychiatric acute inpatient services were medically necessary for 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.