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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for inpatient hospitalization services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. This  patient was admitted to the inpatient unit due to possible suicidal ideation and issues with relationships and inappropriate behaviors on the internet.  On an initial evaluation, the patient reported some possible passive suicidal ideation. This passive suicidal ideation appeared to abate after her first day in the hospital. She did not have any active suicidal ideation or plans to harm herself and did not make any attempts to harm herself or others during her hospital stay. She was not prescribed any psychotropic medications, as her mood became euthymic after a brief time in the inpatient unit. She was noted to get along well with peers and was happy. It appears that a brief inpatient stay was warranted due to the need for evaluation of her potential suicidal ideation in the context of continued depressed mood as well as a stressful home environment.Due to the fact that the patient was cooperative in treatment and was receptive to her psychotherapy while, she could have transitioned to a less restrictive environment, such as a partial hospital program or an intensive outpatient program, after her symptoms were evaluated and she was confirmed to be free of active suicidal ideation or severe symptoms. It appears that her presentation of distress was due to in large part her relationship with her mother and not due to a primary mental illness. This is due to the fact that she quickly stabilized and improved on the inpatient unit without any medication intervention. 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, patients are scored 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. In this patients case, a portion of the inpatient hospitalization services were medically necessary for the treatment of this patient. However, the records fail to demonstrate the medical necessity of inpatient hospitalization services for the entire duration. Thus, CALOCUS will be applied for a portion of the services in question. In terms of risk of harm, the records support a score of 2. The documentation indicates that the patient was not actively suicidal during the disputed dates of service. The progress notes indicate the patient was happy and jovial with her peers and was not engaging in self-harm behaviors or expressing suicidal ideation. With regards to functional status, the records support a score of 2. The patient has had some issues with level of function, but the progress notes indicate significant improvement after a period of deterioration. With regards to comorbidity, the records support a score of 1. The patient did not have active medical problems or substance use issues. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with family members. With regards to level of support for the recovery environment, the records support a score of 2. The patients parents are involved in treatment. In terms of treatment and recovery history, the records support a score of 3. Her presentation drastically improved, which suggests that the majority of her issues were due to her relationship with her family.  Her improved presentation was not due to psychotropic medications, as she was not prescribed psychotropic medications at the treatment center. It does not appear that there were any other acute interventions responsible for her improved presentation other than separation from her family. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively, and her insight and judgment were noted to be good throughout treatment. In terms of acceptance and engagement of the parent, the records support a score of 2. The patients parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient services. In sum, a portion of the inpatient hospitalization services were medically necessary. Final Result: The reviewer determined that the requested services were partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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.