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

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. The progress notes indicate that the patient presents with numerous eating disorder symptoms such as dietary restriction and purging. The progress notes indicate that the patient engages in eating disorder behaviors when she is not in the program. The progress notes indicate that the patient requested others to go to the bathroom with her so she would not engage in purging behaviors. The patient continues to require near constant supervision in order to refrain from purging behaviors. In addition to her eating disorder behaviors, the patient was noted to have numerous psychiatric symptoms, including mood problems, as well as feelings of hopelessness and helplessness. She was also noted to have suicidal ideation and had engaged in self harm behaviors. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines, the medical records support the medical necessity of the PHP services for treatment of this patients behavioral health issues. The patient was at significant risk of harm (score 3) due to repetitive suicidal ideation and recent self-harm behaviors. The patient has moderate functional impairment (score 3) with reported difficulty completing any schoolwork and withdrawn socially. The patient presents with minor co-morbidity (score 2) as she does not have significant substance use or medical problems. The patients recovery environment is highly stressful (score 4) as the progress notes indicate that the patients home life is stressful due to her symptoms. Her level of support is moderate (score 3) as her primary caretakers are reported to have difficulty with emotional support. The patient has demonstrated negligible response to prior treatment (score 5) due to extremely minimal positive treatment response in the past as well as current difficulties with weight maintenance and other significant psychiatric symptoms. The patient has acknowledged the existence of her issues but is noncompliant with treatment (score 3). Her parents have been constructive with treatment (score 2) as they are noted to work with the patients providers. This gives the patients presentation a composite score of 25, which correlates with non-secure 24-hour services with psychiatric management such as the services provided at the PHP level of care. Since the patient has not demonstrated adequate treatment progress and continues to have unsafe behaviors, the PHP services provided were and are medically necessary.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 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.