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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) level of care. 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. With regard to risk of harm, the records support a score of 2. The patient has some risk of harm, without current suicidal ideation or a history of suicide attempts. The patient reported one past episode of self-injurious behavior. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient struggles with good sleep hygiene and inconsistent oral hygiene. She is noted to struggle with being independent and is unable to manage time due to dissociative episodes. She requires significant prompting from her mother to complete activities of daily living. She is unable to attend school due to overwhelming anxiety and panic and has significant difficulty focusing on schoolwork. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity, due to the presence of insomnia and poor sleep, which adversely impacts her ability to focus and concentrate. Insomnia can exacerbate anxiety and depressive symptoms and conversely, anxiety and depression can contribute to insomnia. The patient also suffers from migraine headaches. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a moderately stressful environment as she and her mother struggle with effective communication and have some conflict regarding the patients food choices and lack of independence. With regard to level of support of the recovery environment, the records support a score of 3 as the patient is noted to have a good social support network of family and friends, but reports feeling that her mother is invalidating and dismissive, and that her mother reacts defensively. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as prior treatment has included outpatient therapy, psychiatric care, and several psychotropic medications, however the patient demonstrates frequent evidence of innate vulnerability under stress and difficulty resuming progress towards an expected developmental level. With regard to treatment acceptance and engagement, the records support a score of 2. The patient is engaged in treatment but struggles to complete assigned exposure tasks. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. In this patients case, PHP level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and 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 was and is medically necessary for the treatment of this patient. 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.