Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Partial Hospitalization Program (PHP) services. The progress notes indicate that the patient was struggling with numerous mood and behavioral symptoms such irritability, anger, cursing, and noncompliance. The patient had a significant history of substance abuse that included multiple different substances. The patient had recently stepped down from a residential treatment center, and was only making minimal progress in the PHP. The determination of minimal progress was evidenced by the mood issues and by a lack of insight into the patients behaviors. The progress notes do not indicate that the patient was showing adequate insight into the need for treatment of behaviors. It does not appear that the patients coping skills were adequate to prevent substance relapse in any significant manner. 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) medical, addictive 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.Regarding the six CALOCUS dimensions, the patient had some potential for risk of harm, due to repetitive impulsive behaviors, but a lack of suicidal ideation (score = 2). Regarding functional status, the patient had moderate impairment, with difficulty completing any schoolwork and was noted to have difficulty with relationships (score = 3). Regarding comorbidity, the patient demonstrated significant comorbidity, with significant substance use in addition to mental health symptoms (score = 3). The patients recovery environment  level of stress score reflects a highly stressful environment, as progress notes indicate that the patients home life was stressful due to symptoms and parents potential substance use (score = 4). The patients recovery environment  level of support score reflects a minimally supportive environment, as the patients primary caretakers were reported to have difficulty with emotional support and may be abusing substances (score = 3). The patients resilience and treatment history score is poor, due to extremely minimal positive treatment response in the past as well as current difficulties as described above (score = 4). The patients acceptance and engagement  child/adolescent score reflects an obstructive response, as the patient acknowledges the existence of issues but is noncompliant with treatment (score = 3). The patients acceptance and engagement  parent/primary caretaker score is obstructive, for while the patients parents appear to work with clinicians, they have concerning issues of their own (score = 3). This gives the patients presentation a composite score of 25. This score correlates with a treatment intensity level of five which correlates with `Non-Secure 24-hour services with Psychiatric Management. It is noted that this level of care is noted as residential care, and it is more than an intensive outpatient programming treatment setting which would be level four on the CALOCUS. Therefore, the Partial Hospitalization Program (PHP) services were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.