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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for early childhood partial hospitalization program (PHP) services from 2/13/19 forward. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This patient has demonstrated a low risk of harm (score 1) as the records do not support any suicidal or homicidal ideation or recent aggressive behaviors. The patients functional status is moderately impaired (score 3) given his difficulty completing schoolwork due to his mental health diagnoses. The patient does not have any comorbidities (score 1) as he does not have any substance use issues or active significant medical problems affecting his behavioral health diagnoses. The progress notes indicate that the patient has a diagnosis of autism with some motor tic behaviors. The patients recovery environment is minimally stressful (score 1) as the progress notes indicate that the patients home life is supportive without enduring difficulties. The patients recovery environment is also highly supportive (score 1), as the patients primary caretakers are reported to have been actively involved in the patients treatment. Further, the patient has shown limited response to prior treatment (score 3) given the lack of prior treatment and minimal progress in current treatment. The patient has been obstructive to treatment (score 3), which is consistent with his behavioral health condition that limits his insight into his need for treatment. Moreover, the patients parents have been constructive in treatment (score 2) as they have actively worked with the patients providers. This gives the patients presentation a composite score of 15, which correlates with intensive outpatient services. According to the CALOCUS, the patient is a candidate for treatment at a lower level of care. Thus, the early childhood PHP services were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were not and are 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 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.