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

The patient is a female diagnosed with major depressive disorder, generalized anxiety disorder, and attention deficit disorder. The patient was also noted to have social anxiety and an eating disorder. The records document a history of self-harm and suicidal ideation, with school refusal, and social isolation. On 10/24/18, the patient was noted to be withdrawn, fatigued, and had a depressed mood. The patient reported hopelessness and helplessness but denied suicidal or homicidal ideation. The patient endorsed not attending school and rarely spending time with friends. On 10/28/18, the patient reported suicidal and homicidal ideation. On 11/5/18, the patients mood was noted to be improved. At issue in this case is whether PHP level of care services provided from 10/24/18 through 11/9/18 were medically necessary for the treatment of the patients medical condition. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The patients CALOCUS scoring for the dates 10/24/18 through 11/4/18 support the medical necessity of the PHP services at issue. For risk of harm, the patients score is 3, due to significant potential for the risk of harm as evidenced by depression, anxiety, hopelessness, helplessness, and parental report of suicidal and homicidal ideation while at home on 10/28/18. For functional status, the patients score is 3, for moderate functional impairment due to a conflicted relationship with family, disturbances in sleep, an eating disorder, and refusal to attend school. For comorbidity, the patient scored a 3, due to the patient being diagnosed with stomach flu on 10/26/18. In addition, the patient has diagnoses of major depressive disorder, social anxiety disorder, obsessive compulsive disorder, and eating disorder. For recovery environment, the patients score is 3, indicating a moderately stressful environment due to the patient not attending school and suicidal and homicidal ideation on 10/28/18. For environmental support, the patients score is 2, due to family participation in treatment. For resiliency and treatment history, the patients score is 4, due to frequent vulnerability under stress, refusal to participate in a therapy session, and low motivation to implement treatment recommendations. For treatment acceptance and engagement, the patients score is 2, due to her refusal to engage in a therapy session and low motivation. For parent engagement, the score is 2, due to parental involvement in the patients treatment. The patients composite CALOCUS score for the dates 10/24/18 through 11/4/18 is 22, which correlates with an intensive integrated service level of care without 24-hour psychiatric monitoring which is consistent with PHP level of care. Therefore, PHP level of care services provided from 10/24/18 through 11/4/18 were medically necessary for the treatment of this patient. However, the patients CALOCUS scoring for the dates 11/5/18 through 11/9/18 do not support the medical necessity of PHP level of care services. For risk of harm, the patients score is 2, due to a history of previous suicidal ideation without current suicidal ideation. For functional status the patients score is 2, due to improved functioning and increased telephone contact with friends. For comorbidity the patients score is 3, due to diagnoses of major depressive disorder, social anxiety disorder, obsessive compulsive disorder, eating disorder, and the patients school refusal. For recovery environment level of stress, the patients score is 2, due to interaction with friends over the phone, and participation in therapy. For recovery environment level of support, the patients score is 2, due to parental involvement in the patients treatment. For resiliency and treatment history the patients score is 2, due to improvement in the patients mood and increased interaction with her family. For acceptance and engagement of the adolescent the patients score is 2, due to her participation in treatment. For acceptance and engagement of the caretaker, the score is 2, due to parental involvement and participation in the patients treatment. The patients composite CALOCUS score for the dates 10/24/18 to 11/4/18 is 17 which correlates with an intensive outpatient level of service. Thus, the PHP level of care services provided from 11/5/18 through 11/9/18 were not medically necessary for the treatment of this patient. In summary, the PHP level of care services provided from 10/24/18 through 11/4/18 were medically necessary, while the PHP services provided from 11/5/18 through 11/9/18 were not medically necessary for treatment of this patient. 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 overturn. 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.