Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 16-year-old female with a past psychiatric history of attention deficit/hyperactivity 
disorder,  inattentive  presentation,  major  depressive  disorder,  severe,  recurrent  episode,  and 
generalized  anxiety  disorder.  The  patients  parent  has  requested  reimbursement  for  partial 
hospitalization program services provided from 12/01/21 through 12/07/21. The Health Insurer 
has denied this request and reported that the services at issue were not medically necessary for the 
treatment of this patient. This denial is the subject of this appeal and determination. The physician 
reviewer found that the 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. For dimension 
1, risk of harm, the records support a score of 3. This dimension assesses potential for harm to self 
or others, or having harm inflicted upon them. The patient has attempted suicide by overdose. She 
has a history of self-harm behaviors. During the period under review, the patient did not endorse 
any suicidal ideation. The patient has attention deficit/hyperactivity disorder and records indicate 
that she continued to have difficulty maintaining appropriate behavior without a great deal of 
support. For dimension 2, functional status, the records support a score of 3. This dimension 
assesses the degree to which a person is able to fulfill responsibilities within developmental 
constraints. The patient has a history of school avoidance and refusal. During the period under 
review, the patient struggled to stay awake in class, had difficulty completing school assignments, 
and struggled to meet parental expectations around chores and activities of daily living. For 
dimension 3, co-occurring developmental, medical, substance use and psychiatric conditions, the 
records support a score of 2. 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 minor co-occurrence given her psychiatric diagnoses and ongoing issues 
with insomnia and poor sleep. For dimension 4A, level of stress in the recovery environment, the 
records support a score of 3. This dimension assesses the stressors in the environment, social 
circumstances,  and  interpersonal  relationships.  The  patients  recovery  environment  appears 
moderately stressful due to longstanding school difficulties, conflictual relationship with her 
mother (which has only recently begun to improve), little to no relationship with her father, and 
limited peer support. There is evidence that role expectations exceed the adolescents capacity. For 
dimension 4B, level of support in the recovery environment, the records support a score of 2. This 
dimension  assesses  the  presence  of  family  and  social  support  to  augment  the  recovery 
environment. The patients recovery environment appears supportive as evidenced by her mothers 
participation in the patients treatment. For dimension 5, resiliency and response to services, 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. Prior treatment has included 
outpatient therapy, psychiatric medication, inpatient psychiatric hospitalization, and residential  treatment.  The  patient  exhibits  moderate  or  equivocal  resiliency/response  to  treatment.  For 
dimension 6, engagement of the patient, the records support a score of 3. The child and adolescent 
sub-dimension assesses ability to form therapeutic relationship within developmental constraints. 
The  patient  appears  to  be  mostly  engaged  in  her  treatment.  However,  her  attention 
deficit/hyperactivity symptoms impair her ability to fully engage and appropriately utilize group 
therapy sessions. She struggled to accept responsibility for her inappropriate and distracting 
behaviors when they were pointed out to her, suggesting difficulty accepting even limited age-
appropriate responsibility. These findings give the patient a composite score of 19, which is 
consistent  with  Level  3  High  Intensity  Community-Based  Services.  Therefore,  partial 
hospitalization program services provided from 12/01/21 through 12/07/21 were not medically 
necessary for the treatment of this patient.