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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services.At issue is whether all or any of the PHP services were medically necessary to treat the enrollees mental health or substance use disorder as defined in Health and Safety code section 1374.72(a)(3)(A).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, this patient met the criteria for PHP services.For dimension 1, the records support a score of 3. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The records do not indicate whether the patient has a history of prior suicide attempts, but she does have a history of self-harm behaviors. The patient reported ongoing suicidal ideation, which improved after lithium was started. However, she continued to report ongoing command auditory hallucinations telling her to end her life. Given these multiple factors, risk of harm was significant. For dimension 2, the records support a score of 3. This dimension assesses the degree to which a patient is able to fulfill responsibilities within developmental constraints. The patient demonstrated serious functional impairment given her ongoing command hallucinations, ongoing suicidal ideation, and significant obsessive-compulsive symptoms.  Furthermore, the records state that she had ongoing conflict with her parents. For dimension 3, the records support a score of 3. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. The patient has significant co-occurrence, considering her diagnosis of depression, schizophrenia, obsessive-compulsive disorder, and anxiety coupled with anorexia, hand tremor, and lithium treatment. Lithium treatment requires close monitoring given its narrow therapeutic index and significant side effects, which the patient is currently experiencing (tremor). Furthermore, patients anorexia can adversely impact her cardiac status.For dimension 4A, level of stress in the recovery environment, the records support a score of 3. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patients recovery environment is moderately stressful due to her ongoing command hallucinations, delusions, and severe obsessive-compulsive disorder symptoms. The records also indicate ongoing conflict with parents, whom she struggles to trust. For dimension 4B, level of support in the recovery environment, the records support score of 2.  This dimension assesses the presence of family and social support to augment the recovery environment. The records suggest that the family environment is supportive, as her parents have gone to significant efforts to ensure the patients safety by reducing her access to lethal means and securing the environment.For dimension 5, the records support a score of 3. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. According to records provided, the patients previous treatment had included residential treatment and eating disorder residential treatment. The patient is taking multiple psychotropic medications, and medications have not helped the patient achieve complete relief of psychotic and obsessive-compulsive symptoms. Per the records, the patient was being cross-titrated to a second atypical antipsychotic, and lithium was added to address suicidality. This is most consistent with moderate or equivocal resiliency and/or response to services. For dimension 6, the records support a score of 3. The child and adolescent sub-dimension assesses the patients ability to form therapeutic relationship within developmental constraints. This patient has been engaging in individual, family, and group therapy and participating appropriately. However, the records indicate that she struggles with utilizing coping skills to manage her symptoms. These findings give the patient a composite score of 20, which is consistent with Level 4, Medically Monitored Community-Based Services. Per the submitted documentation, PHP services were in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, PHP services were medically necessary for the 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 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.