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

Nature of Statutory Criteria/Case Summary: female enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. In cases such as this, an evidence based instrument such as the CALOCUS is used when determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible.  By 8/11/17, the patients risk of harm is scored a (2). The patient was not having active suicidal ideation. Her functional status is moderate with a score of (3). The patient has functional impairment in relation to social situations. Her medical, addictive and psychiatric co-morbidity is scored a (1). This is due to her overall medical stability and lack of substance use. This patients recovery environment, is a (2). She has a stable living environment. Her recovery environment and level of support is highly supportive (1). The patients family is supportive of her treatment needs and are engaged in her treatment. Her resiliency and treatment history is scored a (3), minimal to moderate treatment response overall. The patients acceptance and engagement, is scored a (2). The patient participates in therapy in accordance to her ability to participate. The patients  acceptance and engagement is scored a (2). The parents work actively and constructively with the patients clinicians.  According to CALOCUS criteria, the patients total score is 16 which correlates to a treatment intensity level of two. As such, this score indicates that this patient would be appropriate for outpatient services.  Moreover, the progress notes indicate that the patient was cooperative in treatment. However, she did have some difficulty engaging in group treatment at times due to her psychosis. She did not display any dangerous behaviors while in the PHP. The patient had no significant history of substance use or abuse. It appears that she could have received effective treatment on an intensive outpatient basis, or outpatient basis, due to her lack of self harm behaviors, and lack of active suicidal or homicidal ideation. The supplied documentation does not indicate a need for continued PHP level of care as of 8/11/17. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. PHP care is not the least restrictive environment for the patient. Therefore, PHP services from 8/11/17 forward were not and are not medically necessary for the treatment of this 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.