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

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement for the partial hospitalization program (PHP) services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patients risk of harm score is two (2), some risk of harm. The patient has a history of intermittent suicidal ideation. The expression of suicidality appears to be utilized to manipulate his parents and as a result of not getting what he wants. The patient threatened suicide if he were sent to boot camp. The patient had suicidal behaviors of cutting himself when attempting to manipulate his parents. There was no documentation of a suicide attempt. The patient was hospitalized previously at an inpatient level of care and the provider indicated that no suicidal ideation was expressed during his stay. The patients functional status score is three (3), moderate functional impairment. The patient has a conflictual relationship with his parents. There have been prior acts of violence and threats against his parents. The patients school behavior has deteriorated. From the documentation, the patient appears to meet usual self-care and hygiene. The patient has chronic severe deficits in interpersonal relationships and ability to engage in socially constructive activities and maintain responsibilities. The patients co-morbidity score is three (3), significant co-morbidity. There is no documentation of chronic medical problems. The patients recovery environmental stress score is three (3), moderately stressful environment. The patient has many interpersonal conflicts with his parents which have a significant impact on the family dynamic. His environmental support score is two (2), as he has a supportive environment with parents who are willing to participate in treatment. His resiliency score is three (3), equivocal resiliency and response to treatment. The patient has had an equivocal response to treatment. He has had some minor improvement since his admission. The documentation describes the patient with an even mood, and not irritable. He was noted to be willing to talk and engage. The patient has demonstrated an inconsistent ability to deal with stressors and maintain normal development. He has been obstructive and demonstrated a limited ability to follow through with treatment recommendations. His acceptance and engagement score is three (3). The patient has been ambivalent and distrustful with providers. He minimized and rationalized his problem behaviors and consequences. Based on these criteria, the patient has a composite score of 19, met criteria for an intensive outpatient program (IOP) and could be treated in a less restrictive environment. The patients continued treatment for his depression, behavioral problems, and cannabis use, could have been treated at a lower level of care. Therefore, the PHP services provided were not medically necessary for 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.