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 (AACAP) and American Association of Community Psychiatrists (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS-CASII, 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) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, this patient met the criteria for PHP services. For dimension 1, the patient was at significant risk of harm (score 3) considering her history of inappropriate sexual behaviors, as well as her poor judgment and poor impulse control. The patient was at significant risk for victimization and abuse. The patient also has a history of self-injury and suicidal ideation. The patient was noted to demonstrate poor judgment and poor impulse control with poor mood regulation. The records support an indication or report of incidents of acting without thinking. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given her serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others, which may include impulsive or abusive behaviors. The patient has required significant support around school challenges as well as ongoing parental monitoring with technology use due to history of engaging inappropriately with older men, even while in PHP. The patient was noted to have impaired self-care in the form of irregular eating patterns and skipping meals. For dimension 3, the patient has significant co-occurrence (score 3) due to significant autism spectrum disorder that impacts adversely on the patients ability to manage her mental health issues of depression and anxiety. The records document that the patients developmental disability adversely affected the presenting condition and required significant augmentation or alteration of treatment for the presenting condition or co-morbid condition, and adversely affected the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) given the patients many skills deficits secondary to autism spectrum disorder and attachment issues. There is evidence of role expectations that exceeded the patients capacity given age, status, and developmental level. For dimension 4B, the patients recovery environment was supportive (score 2) since the patients family or primary caretakers were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient showed poor resiliency and response to services (score 4). Overall, the records document that the patient has demonstrated frequent evidence of innate vulnerability under stress and difficulty resuming progress toward expected developmental level. Moreover, the patient has had previous outpatient treatment that has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to interventions, including medication management and therapy. Overall, the notes indicate a history of outpatient therapy to treat depression and anxiety with little success, with the patient continuing to use self-ham and isolation as a maladaptive means to cope. For dimension 6, the patient showed limited engagement in services (score 3) due to reports of attachment issues and a distrustful relationship with clinicians and other care providers. The patient exhibited poor treatment insight and had challenges accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 22, which is consistent with Level 4 medically monitored community-based services: intensive integrated services without 24-hour psychiatric monitoring. Moreover, the PHP services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. 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. 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.