Self-harm Behavior: 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 and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (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 provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. 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 parent of a patient has requested reimbursement 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. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee’s parent is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee entered the residential treatment center (RTC) level of care due to suicidal thoughts, urges and actions of self-harm, and depression. The enrollee’s parents indicate she is secretive about her suicidal ideations. She has difficulty controlling her emotions and becomes impulsive and angry when she does not get what she wants. The enrollee has a history of two suicide attempts and five hospitalizations/treatment programs. She reports a history of self-harming behaviors since sixth grade, with the last self-harming behaviors one month prior. She has no history of alcohol or drug use. There are no medical or legal issues. During her stay at the RTC, the enrollee was compliant with her medications.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) residential treatment center (RTC) services already provided, and (2) RTC services provided and going forward. 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, 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. For dimension 1, the patient was at significant risk of harm (score 3) due to a history of impulsive and risky behaviors, suicidal ideation, and self-harm behaviors. The records noted a history of several suicide attempts.

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 self-harm behavior was denied, the published record says the denial is worth fighting.