Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 16-year-old male with a past psychiatric history of major depressive disorder and 
unspecified  anxiety  disorder.  The  patients  parent  has  requested  reimbursement  for  partial 
hospitalization program services provided from 2/10/22 through 2/23/22. The Health Insurer 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. The physician 
reviewer found that the American Academy of Child and Adolescent Psychiatry (AACAP) and 
American Association for Community Psychiatry (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 is a standardized tool used to 
determine the intensity of services needed for children and adolescents, 6-18 years of age, 
presenting  with  psychiatric,  substance  use,  medical  and/or  developmental  concerns.  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) co-
occurrence of developmental, medical, substance use and psychiatric conditions; (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, the patient met the criteria for PHP level of care 
services provided from 2/10/22 through 2/23/22. For dimension 1, risk of harm, the records support 
a score of 3. This dimension assesses potential for harm to self or others, or having harm inflicted 
upon them. During the period under review, the patient reported increasing suicidal ideation but 
denied plan or intent. He has attempted suicide once by overdose. The patients risk of harm was 
significant. For dimension 2, functional status, the records support a score of 3. This dimension 
assesses the degree to which a patient is able to fulfill responsibilities within developmental 
constraints. The patient has a history of overwhelming anxiety and frequent panic attacks. He 
continues to endorse times of very high depression. He is noted to have extreme dysregulation. 
Recent gains in functioning have been achieved only while participating in the highly treatment 
setting. For dimension 3, co-occurring developmental, medical, substance use and psychiatric 
conditions, the records support a score of 3. This dimension assesses the co-existence of disorders 
across four domains (psychiatric, substance use, medical or developmental) that may complicate 
the course of treatment.  The patient has asthma and is under the care of a pulmonologist. His 
asthma symptoms can mimic anxiety and panic, and anxiety/panic can worsen symptoms of 
asthma. For dimension 4A, level of stress of the recovery environment, the records support a score 
of  3.  This  dimension  assesses  the  stressors  in  the  environment,  social  circumstances,  and 
interpersonal relationships. The patient is isolated. His coping skills appear minimal, and he is 
often overwhelmed by anxiety. He is falling behind in school. For dimensional 4B, level of support 
in the recovery environment dimension, the records support a score of 3.  This dimension assesses 
the presence of family and social support to augment the recovery environment. The patients 
parents are his primary source of support but the patient struggles to utilize this support as 
evidenced by his reluctance/failure to disclose to parents when he is feeling suicidal. For dimension 
5, resiliency and response to services, the records support a score of 4. This dimension assesses 
how past experiences with treatment and recovery might indicate how the patient might respond 
in  the  future.    Prior  treatment  has  included  outpatient  therapy  and  numerous  psychotropic 
medications. Furthermore, the patient exhibits frequent evidence of innate vulnerability under 
stress and difficulty resuming progress toward expected developmental level. For dimension 6,  engagement of the patient, the records support a score of 3. The child and adolescent sub-
dimension assesses the ability to form therapeutic relationships within developmental constraints. 
At times, the patient has  required prompting and encouragement  to engage  in groups. His 
participation in groups is inconsistent. This is indicative of limited engagement. These findings 
give the patient a composite score of 22, which is consistent with Level 4 Medically Monitored 
Community Based Services. Therefore, PHP level of care services provided from 2/10/22 through 
2/23/22 were medically necessary for treatment of this patient.