Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for inpatient psychiatric hospitalization services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, the patient meets the criteria for inpatient psychiatric hospitalization services.For dimension 1, the patient has been at serious risk of harm (score 4) not due to current suicidal ideation, but the patient has engaged in aggression and property destruction during their current admission. The patient also has a history of suicidal ideation, and they have attempted suicide twice. The patient has a significant history of physical aggression towards others, and they have made homicidal threats. The provider noted that the patient has little to no insight into their behaviors and they exhibit poor judgment as evidenced by their continued aggression and property destruction when upset. The records support indication or report of significant impulsivity and physical aggression with poor judgment and insight, and that are significantly endangering to self and others. For dimension 2, the patient has demonstrated serious functional impairment (score 4) as evidenced by their inability to consistently maintain safe and appropriate behaviors. The provider charted that the patient is often in conflict with adults with verbal and physical aggression. The patient has a recent history of refusing to engage in schooling. There is evidence of serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which includes impulsive or abusive behaviors. For dimension 3, the patient has major co-occurrence (score 4) considering their diagnosis of attention-deficit/hyperactivity disorder (ADHD), which is a neurodevelopmental disorder in addition to his psychiatric issues. The poor frustration tolerance and impulsivity that are part of ADHD likely contribute to the patients significant mood dysregulation, anger outbursts, verbal and physical aggression, and property destruction. The records indicate that a developmental delay or disorder is present that significantly reduces functional capacity and ability to participate meaningfully in psychiatric services. For dimension 4A, the patients recovery environment has been highly stressful (score 4) since their behaviors have interfered with his ability to stay at thier home for over one year. The patient has required several placements during this time including wilderness program, therapeutic boarding school, and inpatient psychiatric hospitalization. There is documentation of serious disruption of family and social milieu. For dimension 4B, the patients recovery environment has been minimally supportive (score 4). The records indicate that parents are seriously limited in their ability to provide for the patients emotional and developmental needs. For dimension 5, the patient has exhibited negligible resiliency and response to services (score 5) since prior treatment has included outpatient treatment including multiple medication trials, applied behavior analysis (ABA), a wilderness therapy program, therapeutic boarding school, and two inpatient psychiatric hospitalizations. Past response to treatment has been quite minimal, even when treated at high levels of care for extended periods of time. For dimension 6, the patient has shown minimal engagement in services (score 4). The providers have described the patient as often oppositional and defiant, requiring multiple prompts to comply with unit expectations. The patient is noted to frequently ignore staff requests and redirections, swear at staff, and actively and frequently disrupt assessment and services. These findings give the patient a composite score of 29 which is consistent with Level 6 medically managed residence-based services per CALOCUS-CASII guidelines. In addition, the inpatient psychiatric hospitalization services were and are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the inpatient psychiatric hospitalization services were and 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 evaluation 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.