Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has been diagnosed with atypical anorexia, generalized anxiety disorder, and panic attacks. The patient was admitted to a partial hospitalization program (PHP). She had received outpatient treatment with a registered dietitian and a psychiatrist, resulting in no change in her behavior. The patient had difficulty with relationships with her peers, which resulted in passive-aggressive behavior and self-harm. The patient reported increased anxiety about her body image, restricting food intake, increased exercise, and obsessive food rituals, which led to a 17-pound weight loss. The patient was admitted to an intensive outpatient program. The patients parent has requested reimbursement for partial hospitalization program services utilizing the plate-by-plate approach and intensive outpatient program services using the plate-by-plate approach. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. At issue in this case is whether partial hospitalization program services utilizing the plate-by-plate approach and intensive outpatient program services using the plate-by-plate approach were medically necessary for treatment of the patients medical condition. The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. The patients risk of harm score is 3, due to passive suicidal ideation and urges to self-harm. The patient also scratched her arm due to a sad mood. For functional status, the patients score is 3 due to the patient endorsing an emotional meltdown while doing homework, and continuing to restrict her diet while in treatment. For comorbidity, the patients score is 2, due to the patients generalized anxiety disorder and atypical anorexia. For recovery environment stress, the patients score is 2 as evidenced by a report noting the loss of a friendship due to the patients passive aggressive behavior. For recovery environmental support, the score is 2 due to continuity of family relationships and parental participation in her treatment.  For resiliency and treatment history, the patients score is 3, as she minimized her eating disorder behaviors. For treatment acceptance and engagement of the adolescent, the patients score is 3, as evidenced by the patient continuing to restrict her diet while in treatment.  For treatment acceptance and engagement of the parent, the score is 3 due to the patients parents attending family therapy but struggling to hold the patient accountable with the treatment plan and minimizing her behavior. The patients composite CALOCUS score is 21, which correlates with a partial hospitalization program level of care. Therefore, partial hospitalization program services utilizing the plate-by-plate approach were medically necessary for the patient. The patients CALOCUS scores include the following: for risk of harm, the patients score is 3, due to passive suicidal ideation and self-harm urges. For functional status, the patients score is 3, due to the patients urges to restrict her diet and two attempts to purge. For comorbidity, the patients score is 2, due to the patients generalized anxiety disorder and atypical anorexia. For recovery environment stress, the patients score is 2 as evidenced by a report noting the loss of a friendship due to the patients passive aggressive behavior. For recovery environmental support, the score is 2 due to continuity of family relationships and parental participation in her treatment.  For resiliency and response to treatment, the patients score is 3, as evidenced by her continued anxiety, diet restricting behaviors, and an emotional meltdown during a couple family therapy sessions. The patient also endorsed having low hope and minimal self-trust. For treatment acceptance and engagement of the adolescent, the patients score is 3 due to the patient continuing to restrict her meals and attempts to purge. For treatment acceptance and engagement of the parent, the score is 1, as evidence by the patients parents attending family therapy and holding the patient accountable for eating disorder behaviors. The patients composite CALOCUS is score is 19, which correlates with intensive outpatient services. Therefore, intensive outpatient program services using the plate-by-plate approach were medically necessary for the patient.Final Result: The reviewer determined that the requested services 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 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.