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

Nature of Statutory Criteria/Case Summary: The patients has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) psychiatric level of care services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that the progress notes indicate that the patient was cooperative in treatment at the inpatient hospital. She did not have any difficulty engaging in group treatment, her suicidal ideation resolved rapidly, and her mood improved significantly in a short period of time. She expressed motivation in treatment and also expressed that she had motivation not to harm herself due to the negative effects it would have on her family. However, the provided documentation does not support a need for PHP level of care. The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Based on the documentation, PHP care is not the least restrictive treatment environment for this patient. Current literature indicates that effective self-harm reduction can occur with therapy available on an outpatient basis such as dialectical behavioral therapy (DBT). In cases such as this, an evidence based instrument such as the CALOCUS is indispensable in determining necessary level of care for children and adolescents, to insure their level of care meets their individual needs at the least restrictive setting possible. This patient presents with some risk of harm (score 2) given the lack of active suicidal ideation and history of self-harm. The patient demonstrated moderate functional impairment (score 3) in relation to social situations due to her anxiety but reported improved grades. The patient is noted to be medically stable without substance use (score 3). The patients recovery environment is mildly stressful (score 2) with a stable living environment, and a highly supportive family who is engaged in her treatment (score 1). The patient has demonstrated equivocal response to treatment (score 3) with improvement in the hospital setting after a few days of treatment. The patient has been constructive in treatment (score 2) as she has participated in therapy in accordance to her ability to participate. Further, the patients parents have worked actively and constructively with the patients providers (score 2). This gives the patient a composite score of 16, which correlates with outpatient services. This score is judged by the acuity of the patients symptoms and environment during the period under dispute. According to the CALOCUS, the requested level of care criteria were not met. Thus, the PHP psychiatric level of care services were not and are not medically necessary for treatment of this patients behavioral health issues. 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.