Partial Hospitalization denials in California external review

What the reviewers wrote

Where the denial was overturned

A 20-year-old female enrollee has requested acute inpatient services, residential treatment services, and partial hospitalization services for treatment of her eating disorder. Findings: The physician reviewer found that the submitted medical documentation indicates that the severity of the patient’s eating disorder and restrictive behavior was well documented on admission to the acute inpatient treatment facility. Physical exam noted dehydration and lanugo. She presented with severe distortion of body image, an intense desire for thinness and preoccupation with thoughts of being overweight. However, after approximately three weeks, the patient had experienced some improvement, as her weight was 99% of ideal body weight. Additionally, her vital signs were stable, an NG tube was not required, suicidal ideation was not present, and there was no documentation of severe mood disturbance.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization services. The submitted documentation supports the medical necessity of the services at issue. This patient reported an early age of first use. His alcohol use was complicated by a history of cancer and co-occurring depression and anxiety. This is of particular relevance since it has been well-established that anxiety-ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes. Notwithstanding, the patient’s alcohol use and psychiatric symptoms were impairing his daily routine and contributing to significant impairment across multiple domains of functionality. He was drinking a 12-pack or more on a daily basis. He had history of withdrawal symptoms.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parents of a patient requested reimbursement for the partial hospitalization services provided. Two authorities on childcare 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 parent of an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization services. Findings: The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the services at issue. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. Based on CALOCUS, the patient did not meet the criteria for partial hospitalization services during the dates of service in dispute. In terms of risk of harm, the records support a score of 2. The patient did not have reported suicidal ideation during the dates in question, although she did have impulsivity and temper tantrums. With regards to functional status, the records support a score of 3.

Compare residential, PHP, IOP, inpatient, and withdrawal-management disputes without mixing TMS into the facility-intensity denominator: behavioral-health level-of-care evidence guide.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Partial Hospitalization, then check the rights and deadlines that apply to your plan.