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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization services. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the services at issue. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. Based on CALOCUS, the patient did not meet the criteria for partial hospitalization services during the dates of service in dispute. In terms of risk of harm, the records support a score of 2. The patient did not have reported suicidal ideation during the dates in question, although she did have impulsivity and temper tantrums. With regards to functional status, the records support a score of 3. The patient had moderate functional impairment. The records documented expressive language delay and auditory processing problems. She had chronic deficits in interpersonal relationships and had limitations in her ability to engage in socially constructive activities. In terms of comorbidity, the records support a score of 3. The patient had comorbidities of attention deficit/hyperactivity disorder, oppositional defiant disorder, and anxiety disorder. The patient did not have any medical problems which required 24-hour monitoring. With regards to environmental stress, the records support a score of 3. The patient had a moderately stressful environment. The patients sibling has serious medical problems. In terms of environmental support, the records support a score of 2. The patients parents are supportive of the patient. With regards to resiliency, the records support a score of 2. The patient had a positive response to treatment. In terms of acceptance and engagement, the records support a score of 2. The patient has typically cooperated with staff. At times, she has had tantrums and other behavioral challenges. Therefore, the records support a composite score of 17. Based on these criteria, the patient meets criteria for an intensive outpatient program and could be treated in a less restrictive environment. The patient continued to need treatment for her attention deficit/hyperactivity disorder, oppositional defiant disorder, anxiety disorder, and behavioral dysregulation, but this could have been done in a less restrictive environment. All told, partial hospitalization services provided from the date of service in question, forward, were not and are not medically necessary for the treatment of this patient. 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 expertise 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.