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

Nature of Statutory Criteria/Case Summary:  The parent of a six-year-old male enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) necessary for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patients risk of harm score is two (2), some risk of harm. The patient does not have any suicidal ideation or homicidal ideation. The patient has no history of any suicide attempts. The patient is impulsive and becomes physically aggressive during an emotional outburst. The patients functional status score is three (3), moderate functional impairment. The patients behavior has resulted in being suspended from school. He is at risk for being expelled. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of having attention deficit disorder and having exposure to alcohol as a fetus. The patient is medically stable. The patients recovery environmental stress score is two (2), mildly stressful environment. The patient will frequently throw tantrums and will get physically aggressive with others. However, his parent is accommodating to the patient and his home environment is safe and stable. The patients environmental support score is two (2), supportive environment. The patient has supportive parents. The patients parent is actively participating in treatment. The patients resiliency score is three (3), equivocal resiliency and response to treatment. The patient has made modest improvements in his behavior since starting the PHP. He has had 10% less tantrums and has more tantrums at home than during treatment. He continues to have aggressive behaviors. The patients acceptance and engagement score is three (3), obstructive. The patient is ambivalent about relationships with providers. He will participate in treatment passively but at times will become resistant and engage in tantrums and aggressive behaviors. Based on these criteria, the patient has a composite score of 18, which would meet criteria for an intensive outpatient program (IOP). The patient could be treated in a less restrictive environment. Although the patient continues to need treatment for his aggressive and disruptive behaviors, this can be accomplished at a lower level of care. Therefore, PHP services provided were not and are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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.