Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for all or any of the PHP services provided at Rowi Teen and Parents Wellness. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to the presence of suicidal ideation, a history of two suicide attempts within the past year, and disordered eating that compromised her ability to care for herself. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patients ongoing struggles with eating, mood swings, auditory hallucinations, and paranoia. The patient reported that she ate more consistently while participating in treatment in a structured, protected, and/or enriched service of PHP than at home. With regard to comorbidity, the records support a score of 1. The patient did not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to a disruption of family milieu and an assault a few months prior during an inpatient hospitalization. With regard to level of support of the recovery environment, the records support a score of 3 due to the parents difficulty in enforcing and maintaining expectations for meal consumption and supporting the patients mental health issues at home.  In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment due to ongoing struggles with mood swings, disordered eating, and suicidal ideation even after two inpatient hospitalizations and three months of residential treatment. With regard to treatment acceptance and engagement, the records support a score of 2. The patient participated in treatment. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. This is consistent with the level of care that the patient received at the PHP. 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 at Rowi Teen and Parents Wellness were medically necessary for the 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 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.