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

Nature of Statutory Criteria/Case Summary:  An enrollees parent has requested reimbursement for all or any of the partial hospitalization program (PHP) services rendered from 3/05/21 to 3/14/21.At issue in this case is whether all or any of the partial hospitalization program (PHP) services rendered from 3/05/21 to 3/14/21 to treat the patients mental health or substance use disorder were medically necessary as defined in Health and Safety code section 1374.72(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to current suicidal ideation without clear intent or plan, as well as a history of suicidal behavior. Additionally, the patient demonstrated impulsive behavior, as demonstrated by drinking essential oil and ingesting other non-edible substances, as well as self-harm.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment, due to the patients struggles with online school and difficulties with interpersonal interactions.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to recent diagnosis of autism spectrum disorder, along with depression and anxiety.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to disruptions caused by the COVID-19 pandemic, including online school, as well as some conflict with parents.With regard to level of support of the recovery environment, the records support a score of 2 due to her parents active participation in treatment and treatment planning.In terms of resiliency and treatment history, the records support a score of 4. The records document poor resiliency and/or response to treatment due to the patients symptoms persisting after three months of residential treatment, an inpatient hospitalization, and over two months of PHP treatment. With regard to treatment acceptance and engagement, the records support a score of 2 due to her active participation in treatment.Thus, the patient has a total score of 19. Per the CALOCUS algorithm, the recommended level of care during the period under review in this case is Level Three: High Intensity Community Based Services. This is consistent with intensive outpatient services. The patient at the PHP level of care for over two months, so it was clinically appropriate for the patient to step down to a lower level of care at that time. In this patients case, PHP level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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. Thus, the PHP services rendered from 3/05/21 to 3/14/21 were not medically necessary for the treatment of the patients medical condition. 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 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.