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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage 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 meets the criteria for PHP services. For dimension 1, the patient has been at significant risk of harm (score 3) due to a history of attempting suicide by overdose in 2019, which required hospitalization. The patient also reported a second suicide attempt, the details of which are unknown. The patient has a history of self- injurious behaviors in the form of superficial cutting on a daily basis, most recently one week prior to admission. The patient has not reported suicidal ideation since admission to PHP. The patient recently began identifying as male and prefers male pronouns, which is considered an additional risk factor for suicide. Given the history of suicidal behaviors and additional risk factors of depression, anxiety, impulsivity, and gender identity issues, the patients risk of harm is estimated to be significant. No active suicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given the refusal to attend school, inability to complete homework, and poor grades. School behavior has deteriorated to the point the patient has faced some school disciplinary action and is at risk for placement in an alternative school program. For dimension 3, the patient has significant comorbidities (score 3) with a history of asthma and migraine headaches. Asthma can exacerbate anxiety and vice versa. Migraine headaches can also contribute to distress and mood dysregulation. Medical conditions are present that may adversely affect, or be adversely affected by, the presenting condition. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The records document a lack of contact with biological father for several years, history of being bullied, few identified friendships, and recent declaration of identifying as male gender. This supports a disruption in family and social milieu. For dimension 4B, the patients recovery environment has been supportive (score 2) considering the support from family including a sibling and improvement in relationship dynamics with the patients mother. Continuity of family is only occasionally disrupted and/or relationships with family are only occasionally inconsistent. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The provider noted that the patients prior treatment history is extensive and includes outpatient therapy, medication management, inpatient psychiatric hospitalization, and RTC. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. For dimension 6, the patient has been constructive in treatment (score 2) due to reports of adequate engagement in the therapeutic interventions and attendance of most groups. Able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 20, which is consistent with Level 4 medically monitored community-based services. Therefore, the PHP services were and are medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were and are 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.