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

An enrollee who was admitted for partial hospitalization program level of care.  In an individual session, she reported cutting on herself one month prior to admission. She is noted to have used alcohol and cannabis. Her body mass index was noted to be. She denied a history of medical problems. The patient had a history of binging and purging as well as food restriction, body checking, and fear of certain foods. A review of the records indicates that the patient was feeling uncomfortable in her own skin.  The patient expressed urges to purge or restrict. On, she reported stress regarding meals. On, the patient reported minimal anxiety with transitioning to intensive outpatient program (IOP). Per the records, her diagnoses included major depressive disorder, bulimia nervosa, and anxiety. The patients parent has requested reimbursement for partial hospitalization program services provided through. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The progress notes indicate that the patient was not suffering from any active suicidal or homicidal ideation or self-harm thoughts. There is no indication that the patient was experiencing psychosis.  The patient appeared to be underweight and following her meal plan as evidenced by meal plan compliance. She was noted to be cooperative with treatment. The progress notes do not indicate that she was engaging in self-harm or aggression, and there was no indication of substance use.  She continued to have some depression and anxiety during her treatment. 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, treaters 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 is then used to determine the level of care needed. Her CALOCUS composite score is 16, which is scored as follows based on her symptoms:    1.Risk of harm  some  2. The patient was not having active suicidal ideation but has a history of self-harm. 2.Functional status-moderate  3. The patient has functional impairments in social situations and school due to her eating disorder symptoms and was attending to activities of daily living in a developmentally appropriate manner.3.Medical, addictive and psychiatric comorbidity  none - 1. This is due to her overall medical stability and lack of current substance use.4.Level of stress of the recovery environment-mild  2. The patient has a stable living environment. For level of support of the recovery environment  highly supportive  1. The patients family is supportive of her treatment needs and are engaged in treatment.5.Resiliency and treatment history  equivocal 3. It is apparent the patient had a good treatment response overall in the PHP, with improvement noted after several weeks of recent treatment. 6.Acceptance and engagement, child/adolescent-constructive  2. The patient participates in meal planning.  Acceptance and engagement of the patient-constructive  2.  The parents work actively and constructively with clinicians. The patient had a composite score of 16. This correlates with outpatient services. This score is judged by the acuity of the patients symptoms and environment during the treatment. According to the CALOCUS, the requested PHP level of care criteria was not met. Therefore, the request for PHP provided on the dates requested for reimbursement are not medically necessary. Final Result: The reviewer determined that the requested services 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.