Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 16-year-old male with a past psychiatric history of disruptive mood dysregulation 
disorder,  cannabis  use  disorder,  severe,  attention  deficit  hyperactivity  disorder  and  major 
depressive disorder. The patients parent has requested reimbursement for mental health partial 
hospitalization provided from 10/08/20 through 11/25/20. 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, this 
patient met the criteria for mental health partial hospitalization provided from 10/08/20 through 
11/25/20. 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. The patient was noted to 
experience passive suicidal ideation during the period under review. He struggled with impulsivity, 
exhibited poor frustration tolerance, and was noted to have difficulty regulating his emotions. 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. During the 
period under review, the patient was often argumentative and disrespectful to treatment staff and 
his peers. He was noted to instigate arguments with peers and cause disruption to the treatment 
programming. He required a lot of support from staff to complete homework and treatment 
assignments. Prior to admission, he had missed a significant amount of school and was failing 
academically. Recent gains in functioning have been achieved only while participating in the 
highly supervised 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.  This  patient  struggled  with  a 
neurodevelopmental disorder (ADHD), several psychiatric disorders, and a substance use disorder 
(cannabis). His use of cannabis can exacerbate anxiety. For dimension 4A, level of stress in the 
recovery environment, the records support a score of 3. This dimension assesses the stressors in 
the environment, social circumstances, and interpersonal relationships. The patients parents are 
frustrated with his defiance and disregard for parental expectations.  The records indicate a 
conflictual relationship with parents and lack of academic progress or success. For dimension 4B, 
support in the recovery environment, the records support a score of 3. This dimension assesses the 
presence of family and social support to augment the recovery environment. According to the 
records, support in the recovery environment is limited. 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,  psychiatric  treatment  including  medication  management, 
intensive outpatient treatment, a previous partial hospital program, and psychiatric residential 
treatment. 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. Records indicate that the patient struggled to engage in treatment 
consistently and appropriately. He frequently required significant prompting to participate and 
then  would  become  argumentative  and  defensive.  He  avoided  taking  accountability  for  his 
behaviors and exhibited little insight. 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. For this reason, the partial hospitalization program level of care 
services provided from 10/08/20 through 11/25/20 were medically necessary for treatment of this 
patient.