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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for partial hospitalization program (PHP) level of care services. 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. Applying the CALOCUS-CASII framework, the patient met the criteria for PHP level of care services.For dimension 1, the patient was at some risk of harm (score 2) due to repeated threats of suicide, especially when the patient is dysregulated and/or arguing with his parents. The records document mild suicidal ideation with no intent or conscious plan and with no past history. For dimension 2, the patient demonstrated moderate functional impairment (score 3) since he refused participation in school or completing schoolwork as expected. The provider noted that the patient was often late for PHP or missed therapy appointments. The patient has a conflictual relationship with his parents. The patient was conflicted, withdrawn, or otherwise troubled in relationships with peers, adults, and/or family, but without episodes of physical aggression. For dimension 3, the patient has significant co-occurrences (score 3) including ADHD, which is a neurodevelopmental disorder in addition to depression and anxiety. ADHD can cause mood dysregulation which can contribute to the onset and maintenance of depression. Furthermore, ADHD can also lead to, and exacerbate, anxiety due to ongoing difficulties managing obligations and expectations of daily life. A developmental disability was present that may have adversely affected the presenting condition, and/or may have required significant augmentation or alteration of treatment for the presenting condition or co-morbid condition, or adversely affected the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patient had significant conflict in the home. The patients mother struggled with appropriately regulating her mood when the patient was escalated, and she reportedly became dysregulated herself. The patient also identified school as a stressor. There was disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) due to his mothers struggles with appropriately regulating her mood when the patients mood escalated and then she became dysregulated herself. The records indicate that the patients mother had a difficult time responding appropriately to the patients outbursts. The patients father is often traveling and unavailable for support. The patient reported that he felt disconnected from his family. The patients family has limited ability to respond appropriately to the patients developmental needs and/or problems or was ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to services (score 3). Prior treatment has included outpatient therapy, psychiatric care including psychotropic medications, and an IOP. The patient demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development. Previous experience in treatment at low level of intensity was not successful in relief of symptoms or optimal control of symptoms, and developmental pressures and life changes caused some deterioration in function. For dimension 6, the patients parents were minimally engaged in services (score 4). The records document that the patients father travels often and missed sessions or attended virtually. The patients mother struggled to utilize feedback to change how she responds to the patient when he is dysregulated, and she became dysregulated herself. The patients parents were able to accept the patients need to change but were unable or unwilling to consider the need for any changes in other family members. These findings give the patient a composite score of 21, which is consistent with Level 4 medically monitored community-based services. Moreover, the PHP services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the PHP services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.