Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested reimbursement for partial hospitalization program (PHP) services provided from 6/07/21 through 6/29/21.At issue is whether the PHP services provided from 6/07/21 through 6/29/21 were medically necessary for treatment of the patients mental health or substance use disorder for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care, (ii) clinically appropriate in terms of type, frequency, extent, site, and duration, and (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.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, this patient met the criteria for mental health services provided from 6/07/21 through 6/29/21.With regard to risk of harm, the records support a score of 3. The patient has a history of suicidal ideation and attempting suicide. He has a history of self-injurious behaviors in the form of cutting on his arms and legs. During the period under review, patient endorsed continued severe depressive symptoms and moderate anxiety symptoms. He endorsed continued suicidal ideation, although less severe than previously. He also endorsed increasing anger and thoughts of wanting to hurt his peers. The patients risk of harm was significant.In terms of functional status, the records support a score of 3. During the period under review, records indicate that the patient struggled with completing chores at home and was not participating in activities he previously enjoyed.  The patient was also noted to struggle with reaching out to friends for support when emotionally upset. Prior to admission, the patient was failing in school.With regard to co-occurrence of conditions, the records support a score of 3. This patient has significant comorbidity. He struggles with depression, anxiety, and insomnia. The patients anxiety and depression can cause and/or worsen insomnia and conversely, insomnia can exacerbate depressive and anxiety symptoms. The patient also has a history of disordered eating and dietary restriction. Malnutrition can impact mood and anxiety symptoms and cause other medical sequelae.In terms of level of stress of the recovery environment, the records support a score of 3. The patients environment appears to be moderately stressful. The patient identifies as LGBTQ. His family is religious, and he perceives that they are not accepting of his sexuality and mental health struggles. He has been bullied and was failing in school prior to admission. His mother has bipolar disorder.With regard to level of support of the recovery environment, the records support a score of 3. The patient endorses feeling as though he was a mistake and does not belong in his family. He does not view his family as supportive and believes that they do not care about him. The records indicate that his parents struggled with validation at times. This is consistent with limited support in the environment.In terms of resiliency and response to services, the records support a score of 3. Limited information regarding previous treatment is noted in the records provided. The records do suggest that the patient has demonstrated inconsistent and/or equivocal capacity to deal with stressors and maintain normal development, and developmental pressures and life changes have caused some deterioration in function as evidenced by his failing grades. This is most consistent with moderate or equivocal resiliency and/or response to treatment.With regard to engagement in services, the records support a score of 2. According to records, the patient was mostly engaged constructively in treatment. Some group notes indicate lack of participation or distractibility. Thus, the patient has a total score of 20. Per CALOCUS-CASII, the recommended level of care is Level 4 Medically Monitored Community Based Services. This level of care is consistent with PHP level of care. In this patients case, PHP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, PHP services provided from 6/07/21 through 6/29/21 were medically necessary for treatment of the patients medical condition.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 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.