Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for partial hospitalization program (PHP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing 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) developmental, medical, substance use 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. Applying the CALOCUS framework, the patient met the criteria for PHP services. For dimension 1, the patient was at significant risk of harm (score 3) due to his history of suicidal ideation, excessive substance use, stealing, and other defiant behavior. Indication or report of incidents of acting without thinking as well as breaking laws. For dimension 2, the patient demonstrated moderate functional impairment (score 3), as demonstrated by his conflict with family and inconsistent completion of activities of daily living. Conflicted, withdrawn, or otherwise troubled in relationships with peers, adults and/or family, but without episodes of physical aggression. For dimension 3, the patient has significant comorbidities (score 3) given the combination of significant substance use and other mental health symptoms. Substance abuse is present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The records document a high degree of family conflict as well as exposure to parental substance use. The patient was exposed to substance abuse and its effects. For dimension 4B, the patients recovery environment provided limited support (score 3) due to his parents difficulties in making recommended changes during treatment. The patients family demonstrated limited ability to respond appropriately to the patients developmental needs and/or problems and were ambivalent toward meeting these needs and addressing these problems. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4), considering his continued mood and anxiety symptoms, self-harm, and substance use despite weeks of intensive treatment. Previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. For dimension 6, the patient was constructive in treatment (score 2). The provider noted that the patient participated in treatment milieu. The patient was unable to define the problem, was able to understand and accept how others define the problem and its consequences. These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services, such as PHP. Per CALOCUS, Payer oversight may be required for this level of service, but reviews should not be required more often than every four weeks. For these reasons, the PHP treatment was medically necessary for 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. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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.