Reactive Attachment Disorder 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, 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 for residential treatment center (RTC) services 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 RTC services. For dimension 1, the patient was at serious risk of harm (score 4) due to report of significant impulsivity and physical aggression, with poor judgment and insight, and that were significantly endangering to self or others.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found that in order to objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria will be applied. This is an accepted, national standard for determining the appropriate level of care for adults. With regards to risk of harm, the records support a score of 2. There was no documentation of prior suicide attempts, and the patient did not have suicidal ideation. In terms of functional status, the records support a score of 3. The patient had moderate impairment and had significant deterioration in his ability to fulfill his responsibilities.

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for the psychiatric residential treatment center for treatment of her behavioral health issues. Findings: The physician reviewer found that initial psychiatric evaluation showed no evidence that there was an emergency mental health problem that would justify admission to a psychiatric residential treatment center. Psychotropic medication was not started until more than two months after admission. The patient’s social history and psychiatric evaluation revealed that a major factor in patient’s depression, suicidal behavior, feelings of abandonment, and loneliness were likely indications of reactive attachment disorder (RAD), which was one of the diagnoses initially considered.

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 reactive attachment disorder, then check the rights and deadlines that apply to your plan.