Self-injurious 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 (1) inpatient hospitalization and (2) electroconvulsive therapy services (12 treatments).With regard to risk of harm, the records support a score of 5. The patient has an extreme risk of harm, due to a history of suicidal ideation, self-harm, and aggression towards others. During her hospitalization, she has been unable to go more than three days without the use of four-point restraints and no more than one day without self-harm or aggression towards others. In terms of functional status, the records support a score of 5. The documentation noted severe functional impairment as the patient struggles to complete her activities of daily living, including attending to her hygiene.

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

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for residential treatment center (RTC) 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 authorization and coverage for inpatient psychiatric hospital program with a complete medication wash and a psychiatric evaluation. 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.

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