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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for partial hospitalization program (PHP) level of care services. Findings:  The physician reviewer found that 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. The six dimensions include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, the patient met the criteria for the PHP level of care services.For dimension 1, the patient was at significant risk of harm (score 3) due to a history of one previous suicide attempt by overdose on clonidine, which is a cardiac medication. The patient also has a history of impulsivity and becoming distressed over trivial or insignificant events. The records support no active suicidal or homicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient demonstrated moderate functional impairment (score 3) due to struggles with severe panic and anxiety, school refusal, low motivation, hopelessness, and conflict with parents. The provider described the patient as experiencing anxiety and distress triggered by trivial events. The provider charted that the patient misperceived social interactions and had become increasingly isolative and avoidant. The patient required a fair amount of support to prioritize responsibilities as well as for organization and time management. There is report that recent gains in functioning were achieved only while participating in treatment in a structured, protected, and/or enriched service. For dimension 3, the patient had minor co-occurrence (score 2). The records document that the patient struggled with insomnia for which he was treated with clonidine. The records support that self-limited medical conditions were present that were not immediately threatening or debilitating and had no impact on the presenting condition and were not affected by it. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patients parents are separated, and his older brother has special needs. The patient struggled in his relationship with his mother. The patients father was noted to have difficulties with listening to the patient. The patient had a falling out with friends prior to admission. The patients parents struggle with their own mental health issues. The records document disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) since the patients family presented as supportive, the patients father struggles to regulate his emotions. The patient had few friends and struggled to utilize available support. The provider noted that during a family therapy session, the patients father threatened to punch the patient. The patients family demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient exhibited poor resiliency and response to services (score 4). The records document that prior treatment has included psychiatric treatment including medication management, IOP, psychiatric residential treatment, wilderness treatment, and inpatient psychiatric hospitalization. The provider described the patient as having anxiety and distress that was triggered by trivial events. The patient exhibited frequent innate vulnerability under stress and difficulty resuming progress toward expected developmental level. For dimension 6, the patient showed limited engagement in treatment (score 3). The records indicate that the patient struggled to consistently engage in treatment. He also had difficulty utilizing coping skills and minimizing his struggles. The patient was guarded in individual and group therapy, and often used humor to avoid full engagement in treatment.  He was also noted to be defiant with treatment staff. The records document that the patient was unable to participate consistently in treatment, with inconsistent follow-through. These findings give the patient a composite score of 21, which is consistent with Level 4 medically monitored community-based services. Moreover, the PHP services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the PHP level of care services were medically necessary for treatment of this patient.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.