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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for partial hospitalization program (PHP) level of care services.Findings:  The physician reviewer found that (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 2. The patient had some potential for risk of harm, due to a history of self-harm by cutting, symptoms of anxiety and depression, restrictive eating, and passive suicidal ideation. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to significant restrictive eating with purging behaviors. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of anorexia requiring medical monitoring, purging, symptoms including feeling dizzy, cold and irritable, and symptoms of anxiety and depression. 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 tensions with her mother. With regard to level of support of the recovery environment, the records support a score of 3 due to the family appearing stressed with the patients needs and limited follow-through on family- based treatment recommendations. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment due to following through with a therapist, seeing a psychiatrist, and starting on medication management. With regard to treatment acceptance and engagement, the records support a score of 3. The patient appears to feel ambivalent about whether therapy has been helpful. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. This is consistent with the level of care at PHP. In this patients case, PHP level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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 level of care services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 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.