Appeal type: Medical Necessity
Decision: Upheld 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 did not meet the criteria for PHP services . For dimension 1, the patient was at some risk of harm (score 2) due to reports of passive suicidal ideation. The patient indicated that he would not feel safe with access to a firearm. The records reviewed do not indicate a prior history of suicidal or self-harm behaviors. Mild suicidal ideation with no intent or conscious plan and with no past history. For dimension 2, the patient demonstrated moderate functional impairment (score 3) since his symptoms impaired his ability to perform activities of daily living including participating in school and functioning in social settings. The patient continued to endorse concentration and memory problems. He practiced poor hygiene and limited ability to perform activities of daily living. By the time of discharge, the patient reported that his ability to function, memory and concentration were improved, which had helped him complete schoolwork. The records indicated that the patient was able to complete schoolwork while in the PHP. Recent gains and stabilization in function were achieved while participating in treatment in a structured, protected, and enriched service. For dimension 3, the patient has significant comorbidities (score 3) given his history of ADHD and autism spectrum disorder. Autism adversely impacts the patients social success and contributes to social phobia. Developmental disabilities are present that may adversely affect the presenting condition and may require augmentation or alteration of treatment for the presenting condition or comorbid condition or adversely affect the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patient has a history of being bullied, struggling to articulate his emotions, and social isolation. The patient and his father have difficulties with their relationship. This supports a disruption in family and social milieu. For dimension 4B, the patients recovery environment was supportive (score 2) considering his parents participation in family therapy. Family caretakers were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient demonstrated moderate resiliency and response to treatment (score 3) due to ineffectiveness of prior treatment including PHP in 2017 and a therapeutic school. The patient also has an outpatient therapist and psychiatrist. Previous experience in treatment at low level of intensity was not successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient was constructive in treatment (score 2). The records document that the patient was able to engage in treatment, but he struggled with understanding and articulating his feelings. Able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 18, which is consistent with Level 3 high intensity community-based services. Per CALOCUS, the PHP services were not clinically appropriate in terms of frequency for treatment of this patients condition. Therefore, PHP services were not medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).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 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.