Partial Hospital Program denials: what the review data shows

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for autism partial hospital program level of care services. Authors 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.

Nature of Statutory Criteria/Case Summary: The patient’s 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 patient’s ongoing struggles with eating, mood swings, auditory hallucinations, and paranoia.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for partial hospital program (PHP) services. 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.

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with cannabis use disorder. The patient was admitted to a PHP on 8/31/18. On admission, he denied a history of mental health symptoms and any history of suicidal ideation or suicide attempts. His last cannabis use was on 8/10/18. He denied any active medical issues and was noted to be able to complete his activities of daily living. The patient was noted to recognize that he had a substance use problem and expressed motivation for change. On 9/11/18, the patient reported high cravings and a lowering level of anxiety. On 9/12/18, the patient’s urine drug screen was negative. On 9/14/18, the patient was noted to have had a positive impact on his peers in group therapy. On 9/14/18, no post-acute withdrawal symptoms were noted. He also reported a decrease in cravings, rated as six of 10.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Partial Hospital Programwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.