Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement for partial hospitalization program (PHP) level of care 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 anger outbursts at home and use of cannabis, as well as problems with completing ADLs. The records document periods of inability to care for self and maintain physical safety in developmentally appropriate ways. For dimension 2, the patient demonstrated serious functional impairment (score 3) as demonstrated by fights with her mother that involved throwing objects and required physical restraint. The provider reported poor hygiene including not showering for a week, decline in school attendance, and failing grades. The patient frequently failed to achieve self-care/hygiene at levels appropriate to age and/or developmental level and serious disturbances in physical function. For dimension 3, the patient has significant co-morbidities (score 3) given her learning disabilities and recent substance use that declined or stopped during treatment, per urinalysis. Recent substance use that has significant impact on the presenting condition was arrested due to use of highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment was mildly stressful (score 2) considering the disruptions caused by the shelter-in-place order and discomfort with role expectations at school and home. The records document expectations for performance at home or school that create discomfort. For dimension 4B, the patients recovery environment was highly supportive (score 1). The provider reported that the patients parents were active participants in the treatment planning. The patient is noted to have a close relationship with her mother. There was continuity of active, engaged primary caretakers, with a warm, caring relationship with at least one primary caretaker. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to treatment (score 3). The patients mental health and functioning had not improved after a year of outpatient treatment. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient was constructive in treatment (score 2) due to her participation in treatment, with some struggles in fully implementing newly acquired coping strategies. The patient was able to develop a trusting, positive relationship with clinicians and other care providers. This gives the patient a composite score of 17, which is consistent with high-intensity community-based services. The additional days of PHP services requested in this review fall within the four-week recommended window of treatment for Level 4 services. All told, the PHP services were 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.