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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP) services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. As of 7/12/17, the patients risk of harm score is two (2), some risk of harm. The patient does not have a history of suicidal attempts or suicidal ideation. The patient does have episodes of physical aggression mostly in the context of limit setting. The patients functional status score is three (3), moderate functional impairment. The patient was initially admitted due to poor behavior and aggression. However, the notes state that the patient was gaining more confidence and demonstrating good flexibility and was attentive. His behavior had improved since admission to the PHP. The patients co-morbidity score is three (3), significant co-morbidity. The patient has intellectual disability, autism spectrum disorder, ADHD, and intermittent explosive disorder. The patient does not have any major medical problems. The patients recovery environmental stress score is two (2), mildly stressful environment. The patient has minor stressful experiences due to normative transition experiences. The patients environmental support score is one (1), highly supportive environment. The patients parents are supportive and engaged in his developmental needs. The patients resiliency score is three (3), equivocal resiliency and response to treatment. Due to the nature of autism spectrum disorder, the patient will have difficulty even with treatment. However, the patients behavior improved with treatment. The patients acceptance and engagement score is two (2), constructive. The patient has limited insight due to his condition. However, the notes state that the patient is cooperative and friendly to staff. Based on these criteria, the patient has a composite score of 16 and would meet criteria for outpatient treatment and he could have been treated in a less restrictive environment. The patient continued to need treatment for his autism spectrum disorder, ADHD, intellectual disability, and intermittent explosive disorder, but this could have been safely and adequately conducted in a less restrictive environment. Final Result: The reviewer determined that the services at issue were 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 expertise 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.