Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for (1) all or any of (PHP) services provided at Rowi Valencia, (2) all or any  PHP services provided at Rowi Valencia, and (3) all or any of the (IOP) services provided at Rowi Valencia. The (CALOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment.At issue is whether (1) all or any of the PHP services provided at Rowi Valencia were medically necessary for the treatment of this patient.With regard to risk of harm, the records support a score of 3. The patient had a history of suicidal ideation, previous suicide attempts resulting in hospitalization, and self-harm by cutting. The patient endorsed suicidal ideation without a plan. Her Patient Health Questionnaire (PHQ)-9 score of 18 and Generalized Anxiety Disorder-7  score of 15 indicated severe depression and anxiety.In terms of functional status, the records support a score of 3. The records noted impairment in daily functioning, including deficits in hygiene, including not showering or brushing her teeth, and not eating consistently and at a level commensurate with nutritional needs. The patient required prompting to participate and stay on task. The patient reported a continued lack of motivation and sadness. With regard to comorbidity, the records support a score of 3 due to the presence of cannabis dependence and reported difficulty with sleep onset. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful recovery environment due to increasing conflict with her parents. The patient identified school as a specific trigger due to being on campus during a school shooting. With regard to level of support of the recovery environment, the records support a score of 3 due to the parents efforts to arrange treatment for the patient and their participation in treatment; however, the patient did not view parents as supportive and reported that they did not understand her mental health struggles.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to slow progress in the PHP program and a history of hospitalization and outpatient psychotherapy. With regard to treatment acceptance and engagement, the records support a score of 3. The patient participated in group therapies but struggled with motivation.Thus, the patient has a total score of 21. In this case, the recommended level of care was medically monitored community-based services. This is consistent with the level of care that the patient received. Therefore, PHP services provided at Rowi Valencia were medically necessary for the treatment of this patient. At issue is whether (2) all or any of the IOP services provided at Rowi Valencia were medically necessary for treatment of this patient.With regard to risk of harm, the records support a score of 2. The patient had a history of suicidal ideation, previous suicide attempts resulting in hospitalization, and self-harm by cutting. Her PHQ-9 and GAD-7 scores of 10 indicated moderate depression and anxiety.In terms of functional status, the records support a score of 3. The patient continued to struggle with motivation, and reported feeling down, overwhelmed, foggy and confused. With regard to comorbidity, the records support a score of 3 due to the presence of cannabis dependance and reported difficulty with sleep onset. In terms of level of stress of the recovery environment, score of 3. The patient had a moderately stressful recovery environment due to increasing conflict with her parents. The patient identified school as a specific trigger due to being on campus during a school shooting. With regard to level of support of the recovery environment, the records support a score of 3 due to the parents efforts to arrange treatment for the patient and their participation in treatment; however, the patient did not view her parents as supportive and reported that they did not understand her mental health struggles.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal resiliency and/or response to treatment due to slow progress in the PHP program and a history of hospitalization and outpatient psychotherapy. With regard to treatment acceptance and engagement, the records support a score of 3. The patient participated in group therapies but required some prompting to stay on task.Thus, the patient has a total score of 20. In this case, the recommended level of care was medically monitored community-based services. Therefore, IOP services provided at Rowi Valencia were medically necessary for the treatment of this patient. 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.