Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 19-year-old male enrollee has requested reimbursement for partial hospitalization program level of care provided from 1/18/18 through 1/22/18 and 2/01/18 through 2/06/18 and intensive outpatient program services provided from 3/21/18 through 3/26/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health condition.  The physician reviewer found that 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. In terms of risk of harm, the records support a score of 3. This patient had a significant risk of harm, due to two prior suicide attempts in the past year, as well as impulsivity. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment, due to recent gains in a structured treatment setting, and inconsistent ability to participate in program and adhere to rules. In terms of comorbidity, the records support a score of 3 due to post-concussive syndrome as well as substance abuse, anxiety, and attention deficit/hyperactivity disorder. With regards to stress of the recovery environment, the records support a score of 1. The patients environment was minimally stressful, due to absence of recent losses or difficulties. In terms of level of environmental support, the records support a score of 2. The records documented active participation of parents in treatment with occasional conflict between parents. With regards to resiliency and treatment history, the records support a score of 4 due to lack of progress despite multiple attempts at intensive treatment. Also, the patient had two prior suicide attempts within the past year while participating in intensive outpatient treatment. In terms of acceptance and engagement of the patient, the records support a score of 3 due to inconsistent participation in the treatment program. With regards to acceptance and engagement of the parent, the records support a score of 2 due to cooperation with the treatment plan. Therefore, the patient has a composite score of 21. This is consistent with intensive integrated services without 24-hour psychiatric monitoring. This level of care can encompass partial hospitalization or intensive outpatient care, which are the levels of service in dispute. Given the patients two prior suicide attempts in the past year while participating in intensive outpatient care, a level of service lower than this would have place him at significant risk of self-harm. Also, it is important to note that at the end of the period of services at issue, the patient did not transition to a lower level of care. Instead, he was transferred to a higher level of care (inpatient psychiatric unit) due to concerns about risk to himself, peers, and staff at his current program. Therefore, partial hospitalization program level of care provided from 1/18/18 through 1/22/18 and 2/01/18 through 2/06/18 and intensive outpatient program services provided from 3/21/18 through 3/26/18 were medically necessary for the treatment of this patient.