Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 15-year-old male with a past psychiatric history of disruptive mood dysregulation disorder, major depressive disorder, and cannabis use disorder. He was admitted to a partial hospitalization program for the treatment of mood dysregulation characterized by anger dyscontrol and physical aggression, mood symptoms, including amotivation, poor concentration, and distractibility, a decline in functioning characterized by failure to attend school for over two months, and ongoing substance use. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in 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 helps determine the level of care needed. 

With regard to risk of harm, the records support a score of 2. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The patient has a history of suicidal ideation, mood dysregulation, anger dyscontrol, physical aggression, and property destruction. The patient also struggles with impulse control. During the period under review, patient did not exhibit aggression or report suicidal ideation. Given the patientas history, there is some risk of harm. 

In terms of function, the records support a score of 2. This dimension assesses the degree to which a person is able to fulfill responsibilities within developmental constraints. During the period under review, the patient exhibited some mild functional impairment in that he continued to struggle with poor frustration tolerance. However, records indicate that he completed routine hygiene, attended and participated (mostly) in groups, and ate regular meals. This is most consistent with mild functional impairment. 

With regard to comorbidity, the records support a score of 3. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient has significant comorbidity as evidenced by a mood disorder and substance use disorder. 

In terms of level of stress of the recovery environment, the records support a score of 4. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patientas recovery environment appears to be highly stressful. His father died by suicide after his parents separated and were in the midst of a divorce. He does not have a close relationship with his stepfather. The patient also reports a history of abuse.

With regard to level of support of the recovery environment, the records support a score of 3. This dimension assesses the presence of family and social support to augment the recovery environment. Records provided for the period under review provide limited information regarding environmental support. It appears that the family has engaged in family therapy, which suggests some level of parental involvement and support, but records also intimate problems in the relationship between the patient and his stepfather. 

In terms of treatment and recovery history, the records support a score of 3. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patientas previous treatment has included intensive outpatient treatment, which failed to achieve provide optimal control of symptoms. This suggests moderate resiliency and/or response to treatment. 

With regard to engagement of the patient, the records support a score of 3. The records indicate that the patient was engaged, cooperative, and participatory during the period under review. However, records also note during this time the patient struggled to accept responsibility for his actions and blamed others. At other times, he was distracted, exhibited poor frustration tolerance, minimized his cannabis use, and engaged in ablack and white thinking.a This suggests incomplete engagement. 

Thus, the patient has a composite score of 20, which is consistent with Level 4 Medically Monitored Community Based Services. Therefore, partial hospitalization program services provided from 6/27/20 through 6/29/20 were medically necessary for the treatment of this patient.