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 (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, this patient did not meet the criteria for PHP services.With regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to suicidal ideation and urges to self-harm. The records did not note a history of suicide attempts; however, the patients substance use and depression placed her at greater risk of harm. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to lack of motivation, academic failure, and dietary restrictions requiring supervision and support to meet nutritional needs. Gains in functioning appeared to be recent and achieved while in the PHP. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of psychiatric diagnoses and co-occurring substance use. The patient abstained from substances while in the highly structured environment of PHP. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment as her friend group used substances. She reported a problematic relationship with her father and sister, and significant stress from school. With regard to level of support of the recovery environment, the records support a score of 2 due to her parents support, although her friend group is noted as using substances. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment. This appeared to be her first attempt at mental health treatment. The patient showed inconsistent or equivocal capacity to deal with stressors and maintain normal development and the records noted some deterioration in function due to developmental pressures and life changes. With regard to treatment acceptance and engagement, the records support a score of 3. The patient struggled to fully engage in family therapy. She was noted as avoiding disclosure to her father during family sessions.  Thus, the patient has a total score of 18. In this case, the recommended level of care is high intensity community-based services. This is inconsistent with the level of care that the patient received at the PHP. In this patients case, PHP level of care was not accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, PHP services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that 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.