Conduct Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for residential treatment center services. The researchers 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.

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 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.

Where the denial was upheld

The patient is a 15-year-old female who was admitted to an inpatient psychiatric facility on 9/28/04 for treatment of continued running away from home, polysubstance use involving marijuana, amphetamine and cocaine use, promiscuous sex, stealing money, and continued defiance at home. The patient’s psychiatrist noted the patient had a long history of being very oppositional. She was also noted to refuse to take responsibility for her behavior and the patient cited feeling hopeless and worthless as secondary to being adopted. She was initially diagnosed as having a mood disorder – not otherwise specified and oppositional defiant disorder. She was seen in a variety of group therapies and had family therapy with her adopted mother and father via the telephone, but not in person.

The patient is a 17-year-old female with previously diagnosed dysthymic disorder, oppositional defiant disorder, and borderline intellectual function The patient was previously psychiatrically hospitalized in March and July of 2003 due to increasingly aggressive behavior and anger outbursts. A review of past records indicates anger and insubordination have been ongoing problems since the age of three, but have grown measurably in adolescent years. This has included unprovoked choking of her sister, shoving family members, non-compliance with rules at home and at school, lying, stealing, and killing cats, all of this without remorse. The patient later claimed some of her actions such as the killing of the cats were spurred by “voices,” typically that of a man, urging her to do so.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for conduct disorder was denied, the published record says the denial is worth fighting.