ADD denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) 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.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient demonstrated symptoms of withdrawal including sweating, tremor, restlessness, and anxiety. The patient experienced intermittent tachycardia with an elevated heartrate. The patient’s symptoms of withdrawal could safely be managed at a Level 3.5 RTC setting.

Where the denial was upheld

The patient is a 13-year-old male who was diagnosed with attention deficit disorder (ADD) approximately six years ago. He also has a history of vocal and motor tics as well as obsessive behavior. A SPECT scan performed on 3/18/04 demonstrated brain trauma with decreased left and right anterior pole and decreased posterior medial cerebellar profusion as well as parietal lobe dysfunction. The patient’s parent has requested reimbursement for the SPECT scan. The Health Plan has denied coverage stating the SPECT scan at issue is considered experimental.SPECT brain scans are not routine in the evaluation of attention deficit disorder. Even with the history of problems at birth and fetal distress, a SPECT scan is not used except on a research basis. The standard of care for ADD does not include SPECT scanning.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for methylphenidate HCL (Concerta) 54 mg, 90 count every 25 days, at dosage interval of four times a day. The U.S. Food and Drug Administration (FDA) approves the use of Concerta for the treatment of attention deficit hyperactivity disorder (ADHD). The FDA notes that the recommended dosage for adult patients should not exceed 72 mg/day. Researchers report, “The choice of stimulant is influenced by several factors; the most influential factor is the duration of action. Long-acting medication provides benefits long after school and work. It also increases the likelihood of once-daily dosing, thereby eliminating the need for mid-day dosing, making the treatment more private, avoiding stigma and improving adherence to medication.” Concerta is intended to be used once daily.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving add, then check the rights and deadlines that apply to your plan.