Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for psychiatric acute inpatient services. 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 aggression and homicidal ideation. During his inpatient stay, the patient made threatening verbal statements on various dates throughout his admission and he stated that he wanted to kill a peer or staff member. He also attempted to choke peers, and staff, as well as bit staff on numerous occasions requiring restraint and seclusion multiples times on multiple days throughout his admission. Current homicidal ideation with either clear, expressed intentions and/or past hx of carrying out such behavior. The patient expressed ambivalence about carrying out the safety plan and/or his familys ability to carry out the safety plan is compromised. For dimension 2, the patient exhibited serious functional impairment (score 4) given his agitation, aggression, and impulsivity, which made it difficult for him to function in this highly structured environment in both group and individual situations. He struggled with learning and changing his behavior throughout his admission requiring multiple restraint and seclusions to prevent harm to others. The records document serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which included impulsive and abusive behaviors. For dimension 3, the patient has minor comorbidities (score 2) since he sustained injuries from his behavioral issues that required pediatric care. He has severe psychiatric and developmental issues with his disruptive mood dysregulation disorder, ADHD, and likely autism spectrum disorder on psychological testing. Minimal developmental delay, disorder or brain dysfunction was present and had no impact on the presenting condition for which the patient received adequate satisfactory adaptation and/or compensation. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patient lives with his mother, but she was unable to control him in that environment. No visitation or contact with the patients father was noted in the records, and he struggles in his home environment due to stress. There is evidence of disruption of family/social milieu with absence of parent and primary caretakers limited ability to control the patient in their home environment. For dimension 4B, the patients recovery environment was minimally supportive (score 4) as his mother and grandmother visited him, but he did not have the support or father, other relatives, or other community supports. Community resources only partially compensated for unmet material and emotional needs and/or patient had limited or inconsistent access to network. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4) as evidenced by the patients struggles with poor responses to multiple medication trials, individual therapy, group therapy, and milieu therapy. He was placed in restraints and seclusion on a near-daily basis and sometimes multiple times in a day during his stay. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated treatment exposure. For dimension 6, the patient was non-collaborative in treatment (score 4). The providers documented that the patient struggled to engage and use healthy coping skills despite multiple providers attempts to engage him. He attempted to assault his providers. This supports an actively hostile relationship with clinicians and other care providers despite competent efforts to engage with the patient. These findings give the patient a composite score of 26 which is consistent with medically monitored residence-based services. Per CALOCUS, the patients score of 5 on risk of harm, and scores of 4 on functional status, resiliency and treatment history, and acceptance and engagement, support treatment at Level 6 medically managed residence-based services, consistent with acute inpatient psychiatric level of care. Given these findings, the psychiatric acute inpatient services were medically necessary for treatment of 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.