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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program (PHP) services for treatment of her behavioral health condition. The physician reviewer found that in this case, the patient struggles with affective illness, character pathology, relationship distress, social concerns primarily expressed via financial strain, chronic pain and chronic suicidality. According to the documentation submitted for review, discharge initially would have been premature. However, subsequent records do not support continued treatment at the PHP level of care. Initially, although she denied suicidal ideation, the patient was anxious and stressed out.  Staff completed a risk assessment with her spouse and worked to secure a safe home environment.  The following day, the patient was described as anxious, depressed and agitated.  Her anxiety continued the day after and considering the patients depression, history of emotional dysregulation and static risk factors for suicide, it was reasonable to have her return to the program after the weekend.  The patient began showing signs of treatment consolidation, if not saturation. She did not process in one group and fell asleep in another. She enjoyed her day and articulated her goal of staying positive. She continued to deny suicidal ideation.  The following day the patient met with her psychiatrist. She was doing well despite a sad mood with a congruent affect. She denied sleep impairment. Her thought processing was linear and she had no psychotic symptoms. The patient endorsed chronic intermittent suicidal thoughts, but denied ideation, intent or plan at the time. The provider reviewed the safety plan. There was no mention of medication changes, cognitive impairment, substance use or inability to manage activities of daily living. The patient previously reported supportive friends and family, and had safe housing with her spouse who had been in contact with the staff. Thus, a reasonable clinical opportunity for transitioning to a less restrictive treatment setting availed itself. Although the patient remained symptomatic, it was unlikely that partial hospital programming prevented the need for treatment at a higher level of care. Thus, the PHP services initially provided were medically necessary for treatment of the patients medical condition, but not thereafter.  In addition, there is no clinical indication that a resumption of PHP services is medically necessary. The patient had a reassuring psychiatric visit and had a suicide prevention safety plan in place.  The patient had access to outpatient providers. The patients spouse had been involved in safety planning. Further, the patients marginal progress despite extensive treatment at the partial hospital level of care during the episode of illness suggested the need for a modification in the treatment plan. Thus, the resumption of PHP services is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in 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.