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

The patient is diagnosed with mood disorder, attention deficit/hyperactivity disorder, and provisional autism spectrum disorder. In 2016, the patient was hospitalized due to threatening harm to her mother. She had also run away twice. On 6/11/18, the patient was admitted to inpatient psychiatric hospitalization due to behavioral issues and threats of self-harm. On admission, the patient was noted to be restless with a tangential thought process and poor hygiene.  She denied medical problems, substance abuse, and suicidal ideation. On 6/18/18, the patient was noted to be less irritable and less labile. On 6/24/18, the patient was noted to show cooperative behavior with normal mood, speech, and thought process. On 6/28/18, the patient refused to speak with a psychiatrist. On 7/3/18, the patient was diagnosed with provisional autism spectrum disorder. She also had difficulty completing activities of daily living on 7/3/18. On 7/7/18, the patient was noted to be hostile and yelling. At issue in this case is whether inpatient psychiatric hospitalization services that were provided from 6/18/18 through 7/11/18 were medically necessary for the treatment of the patients medical condition. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. For risk of harm the patients score is 2, due to a history of impulsive behaviors and past self-harm threats. She did not endorse suicidal or homicidal ideation and was not experiencing any psychosis during treatment. For functional status, the patients score is 3, due to poor hygiene on admission, deterioration of school behavior, and deficits in interpersonal relationships. For comorbidity, the patients score is 3, due to the patient being diagnosed with autism spectrum disorder on 7/3/18. The patient did not report medical problems or substance abuse issues. She had a labile mood but did not engage self-harm behavior or aggression with peers or staff. For recovery environment level of stress, the patients score is 2, due to a stable living environment but noting the patients disruptive behavior in school. For recovery environment support, the patients score is 2, due parental involvement in treatment. For resiliency and treatment history, the patients score is 3, due to previous treatment not relieving or gaining optimal control of her symptoms, and the patients inconsistent capacity to handle stress. The progress notes indicate that the patient showed significant improvement in her oppositional behaviors. For acceptance and engagement of the adolescent, the patients score is 2, due to participation in her treatment for a majority of the time. The patient was reported to be non-compliant with staff at times but made improvements with treatment. For acceptance and engagement of the parent, the score is 2, due to parental involvement in the patients treatment. The patients composite CALOCUS score is 19, which correlates with a treatment level of intensive outpatient services. Therefore, inpatient psychiatric hospitalization services from 6/18/18 through 7/11/18 were not medically necessary for the patient. Final Result: The reviewer determined that the requested services 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 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.