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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for partial hospitalization program (PHP) services. 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) developmental, medical, substance use 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. Applying the CALOCUS framework, this patient met the criteria for mental health PHP services. For dimension 1, the patient was at significant risk of harm (score 3) due to his history of substance abuse, highly dysfunctional family dynamics in the home, and his parents use of alcohol. The patient is also noted to have a history of suicidal ideation with thoughts of jumping out of a car. Significant current suicidal ideation with some intent and plan, with an ability for the patient to contract for safety and carry out a safety plan. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given his difficulties attending school and managing his stress levels. The patient had reported substance use cravings especially given his difficult family environment. The patient was unable to function well within the school or home environments. The patient had conflicted, withdrawn, or otherwise troubled in relationships with peers, adults and family, but without episodes of physical aggression. For dimension 3, the patient has significant comorbidities (score 3) with diagnoses including oppositional defiant disorder (ODD), generalized anxiety disorder (GAD), autism spectrum disorder (ASD), and attention-deficit/hyperactivity disorder (ADHD). The records also document support for a significant parent-child relational problem and a history of substance use issues. Developmental disability is present that may adversely affect the presenting condition, and/or may require significant augmentation or alteration of treatment for the presenting condition.  For dimension 4A, the patients recovery environment was highly stressful (score 4) considering his stressful living situation involving his parents who were constantly fighting, and his fathers possible substance use problem. This supports difficulty avoiding exposure to substance use and its effects. For dimension 4B, the patients recovery environment provided limited support (score 3) since his parents appeared to want to support the patient, but they also continued to require a lot of support for their own issues. The patients parents exhibited slow progress in terms of their own dysfunctional and negative patterns. Family has limited ability to respond appropriately to the patients developmental needs and problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to treatment (score 3). The provider noted that the patient expressed suicidal ideation and self-harm urges, with thoughts of jumping out of the car given his severe ongoing family stress and dysfunction along with urges to use substances. The patient has demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development.  For dimension 6, the patients parents were incompletely engaged in treatment (score 3). The providers noted that the patients parents have many issues and concerns that compromise their ability to follow through with providers recommendations. This supports inconsistent and/or avoidant relationship with clinicians and other care providers despite competent attempts at engagement. Unable to participate consistently in treatment, with inconsistent follow-through. These findings give the patient a composite score of 22, which is consistent with Level 4, medically monitored community-based services. The patient made some efforts toward improving his mental health while in PHP. Given his struggles and lagging skills, ongoing intensive support at the PHP level was appropriate. Therefore, the mental health PHP services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.