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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for all or any of the partial hospitalization program (PHP) mental health services rendered from 4/27/21 to 5/09/21 at ROWI Teen & Parent Wellness Center in Valencia, California. Findings: 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 mental health services rendered from 4/27/21 to 5/09/21.With regard to risk of harm, the records support a score of 3. The patient has a history of multiple suicide attempts which have led to psychiatric hospitalizations. The patient also has a history of non-suicidal self-harm behaviors. During the period under review, the patient was noted to struggle with passive suicidal ideation and ongoing urges to self-harm, particularly in response to stressors. This indicates significant risk of harm. In terms of functional status, the records support a score of 3. Records describe the patient as struggling to complete schoolwork due to poor focus and concentration resulting from her mental health issues. The patient was also noted to struggle with social isolation and completing chores at home. This is indicative of moderate functional impairment. With regard to co-occurrence of conditions, the records support a score of 2. The patient has minor co-occurrence of conditions considering her diagnosis of depression coupled with generalized and social anxiety. The patients anxiety symptoms can exacerbate depression due to patient reluctance and/or avoidance to seek support due to fears/anxiety. This can lead to social isolation which further compounds depressive symptoms. The patients depression can often compound anxiety symptoms due to distorted cognitions which can preclude the patient from seeking support thus perpetuating a cycle of depression feeding anxiety and anxiety feeding depression.In terms of level of stress of the recovery environment, the records support a score of 4. The patients recovery environment is highly stressful  due to patients conflictual relationship with her mother which has threatened to disrupt the family system. Furthermore, mother struggles with emotion dysregulation and alcohol use. Parents are struggling in their relationship and patient has been witness to their arguments and physical altercations.With regard to level of support of the recovery environment, the records support a score of 3. The patients recovery environment appears to be limited as evidenced by parental involvement in the patients treatment. However, parents exhibit only partial ability to make necessary changes during treatment as evidenced by continued significant parental conflict in view of patient. Outside supports include athletic coaches and friends. This indicates that there are limitations in support.In terms of resiliency and response to services, the records support a score of 3. Previous treatment has included at least one psychiatric hospitalization following patients three suicide attempts. Review of records suggests that patient has demonstrated equivocal/inconsistent capacity to deal with stressors and maintain normal development and recent progress has only been managed with the significant support of her partial hospital program.With regard to engagement in services, the records support a score of 3. According to records, the patient has engaged in treatment and found coping skills. However, even towards the end of period under review, patient struggled to identify things to talk about in family therapy despite the presence of significant maladaptive family dynamics. This suggests limited engagement. Thus, the patient has a total score of 21. Per CALOCUS-CASII, recommended level of care is Level 4 Medically Monitored Community Based Services. This is consistent with PHP level of care. 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 mental health services rendered from 4/27/21 to 5/09/21 at ROWI Teen & Parent Wellness Center in Valencia, California were medically necessary for treatment of the patients medical condition.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.