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 with ROWI Teen and Parent Wellness Center. 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 met the criteria for PHP services.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of suicidal ideation and self-harm behaviors. The patient attempted to gain access to items with which to hurt herself while in the PHP.  The patient was noted as endorsing command auditory hallucinations. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the records noted a poor relationship with one of her sisters, and persistent distressing visual and auditory hallucinations. The patient was noted as sometimes acting on these hallucinations. Recent gains and/or stabilization have been achieved while participating in a highly structured and supportive treatment environment.  With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to a history of polysubstance abuse and nicotine dependence, with sobriety achieved only recently while in treatment, and insomnia. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to a strained relationship with her sister, who was returning from RTC, and identifying her sister as a trigger. She reported feeling very stressed about school. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents support and participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as she continued to struggle with significant mental health symptoms despite prior treatment including outpatient therapy, IOP, PHP, RTC, and inpatient hospitalization levels of care. The patient demonstrated innate vulnerability under stress. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was noted limited participation in groups or individual therapy.  Thus, the patient has a total score of 21. In this case, the recommended level of care was medically monitored community-based services. This is consistent with the level of care that the patient received in PHP. In this patients case, PHP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, PHP services with ROWI Teen and Parent Wellness Center were medically necessary for the 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 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.