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

ure of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing 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) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. For dimension 1, this patient has been at significant risk of harm (score 3) given her history of prior suicide attempts and self-harm behaviors with passive suicidal ideation. The patient has no active suicidal ideation, but she has a history of suicidal behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) with ongoing anxiety and depressive symptoms. The provider noted that the patients symptoms have improved with therapy and medication management, but she has continued difficulties with family and social relationships and school failures. In the recent past months, the patient has endorsed suicidal ideation and self-harm behaviors. The patient demonstrates improvement in function following a period of deterioration. For dimension 3, the patient has significant comorbidities (score 3) with a diagnosis of autism, acute stress disorder, PTSD, anxiety, substance use concerns, documentation of unspecified ADHD, with also concerns for severe parent-child relational issues. The patient has a developmental disability that may adversely affect the presenting condition and may require significant augmentation of treatment for the presenting condition. For dimension 4A, the patients recovery environment is highly stressful (score 4) given her ongoing conflicts with her parents. The provider noted that the patients father invalidates the patient and her mother is emotionally labile. There is serious disruption of the family milieu due to severe conflict. For dimension 4B, the patients recovery environment provides limited support (score 3). The records document that the patients family has positive intentions, but their family dynamics are preventing progress toward meeting the patients needs. The patients family has limited ability to respond appropriately to the patients developmental needs and problems. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4) with limited response to previous mental health treatment, reflecting the need for ongoing multimodal treatment approach. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. For dimension 6, the patient has been constructive in treatment (score 2). The providers have noted concern that the patient continues to have limited insight and engagement. However, the patient is starting to become more constructive and attempting to build a rapport with her providers. Since stepping down to PHP, the patient has been developing a positive therapeutic relationship with her providers. These findings give the patient a composite score of 22, which is consistent with medically monitored community based services, such as PHP. The patient continues with compromised functioning with a history of poor treatment response. PHP is the appropriate level of care to assist with her mood and behavioral stabilization through medication management, individual skills development and ongoing family therapy sessions. For these reasons, the PHP level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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.