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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for inpatient psychiatric hospitalization services. The enrollee has a history of attention deficit hyperactivity disorder (ADHD) and bipolar affective disorder (BPAD). He entered an inpatient psychiatric unit due to worsening psychotic symptoms at home; including auditory hallucinations (AH), delusions about family members and disorganized and aggressive behavior. He was admitted on lurasidone, olanzapine, lithium and chlorpromazine. He demonstrated limited response to multiple antipsychotics. He started a trial of clozapine while titrating off other antipsychotic medications. Lurasidone was tapered off completely. The enrollee started clozapine, 12.5 mg. The dosage increased by 25mg every two to three weeks. His dosage increased to 50mg, with improvement in psychotic symptoms. He showed a marked decrease in internal preoccupation, improved rapport, cooperativeness, and engagement, and more fluid, well-articulated speech. When he demonstrated metabolic side effects of significant weight gain, the primary team tapered him off olanzapine. Upon tapering, there was an immediate improvement in hyperactivity; suggesting he had akathisia from the olanzapine. He became increasingly internally preoccupied for the first several days following the discontinuation of olanzapine. Thus, the clozapine dosage was titrated upward. Close to discharge, he was cooperative with staff, performing all activities of daily living (ADLs) independently with prompting and did not display aggression or agitation. His clozapine dosage was now 100mg in the morning and 125mg at bedtime. He had periods of clarity, linear thought process, and fair rapport; punctured with periods of erratic behavior and unintelligible mumbling. At discharge, his clozapine increased to 100mg in the morning and 175mg at bedtime. Shortly after discharge, he developed new behaviors that made him a danger to himself. He re-entered the inpatient unit later that day. Since admission, he denied auditory or visual hallucinations, but staff observed him mumbling, talking to himself and speaking in gibberish. He inconsistently engaged in groups and therapies. He would answer questions, but when he tried to initiate conversation, people would not be able to understand his response. The six dimensions of CALOCUS, applied in this case, indicate for risk of harm, the enrollees score is 4, due to his clear and persistent inability, given his developmental abilities, to maintain physical safety and/or use the environment for safety. For functional status, the enrollees score is 5, due to extreme deterioration in his interactions with peers, adults, and/or family that may include chaotic communication. For comorbidity, the enrollees score is 3, due to a developmental disability present that may adversely affect the presenting condition and/or may require significant augmentation or alteration of treatment for the presenting condition. For recovery environment level of stress, the enrollees score is 2, due to expectations for performance at home and school that create discomfort, a significant transition requiring adjustment, and minor interpersonal loss or conflict. For recovery environment level of support, the enrollees score is 2, due to family/primary caregivers being willing and able to participate in treatment if requested to do so and having the capacity to effect needed changes. For treatment and recovery history, the enrollees score is 5, as past response to treatment has been quite minimal, even when treated at high levels of care for extended periods of time. For engagement and recovery status, the enrollees score is 5, due to psychosis and an inability to form therapeutic working relationships. The enrollees composite CALOCUS score is 26, which correlates with 24-hr. services with psychiatric monitoring. Medical evidence does support the inpatient services at issue in this clinical setting.Final Result: The reviewer determined that the requested service is medically necessary to treat the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.