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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested reimbursement and prospective authorization and coverage for any or all requested partial hospitalization program (PHP) services from 9/01/21 forward.At issue is whether any or all requested PHP services from 9/01/21 forward were and are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) 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.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. Using CALOCUS, 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) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; 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 had past history of SI, but with no current SI, plan, or intent. The patient had no significant distress the majority of the time at PHP.In terms of functional status, the records support a score of 2. The patient appears to have demonstrated significant improvement in function following a period of deterioration. The patient appeared to demonstrate more stable behaviors and emotions while at PHP, despite some difficult family and therapy sessions. The patient appeared to be participating in school.With regard to comorbidity, the records support a score of 2. The patient has a history of some substance use; however, notes do not indicate a pattern of escalation for this concern at present. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has had challenges with an ex-girlfriend with reluctance to process this and of which meets criteria of having role expectations that exceed child or adolescents capacity given age, status, and developmental level, appearing to require support around this issue. With regard to level of support of the recovery environment, the records support a score of 2. The patient has a supportive family, with the mother appearing to be an advocate for them and participating in treatment as much as possible. In terms of resiliency and treatment history, the records support a score of 1. The patient appears to have responded to the support and treatment provided. The patient has responded to the experience in treatment with better symptom control.With regard to treatment acceptance and engagement, the records support a score of 3. The patient has some indication of having ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. Notes also point to the patient acknowledging existence of problems, but resisting accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. The patient also has appeared to have tendencies to minimize or rationalize distressing behaviors and consequences. These findings give the patient a composite score of 15. The patient did not and does not meet the standard for PHP level of care and could be served at a lower level of care. The patient has appeared stable overall while at PHP with no indication of severe mood or behavioral dysregulation concerns, with no SI/HI/psychosis. In this patients case, PHP level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, PHP services from 9/01/21 forward were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.