Partial Hospitalization Program denials in California external review
In the California DMHC record, independent physician reviewers decided 424 published external-review cases involving Partial Hospitalization Programand overturned the plan’s denial in 62.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Depression | 99 | 66.7% |
| Eating Disorder | 70 | 60% |
| Autism Spectrum Disorder | 31 | 61.3% |
| Anxiety | 30 | 70% |
| Suicidal Ideation | 28 | 75% |
| Post-traumatic Stress Disorder | 27 | 70.4% |
| Bulimia Nervosa | 26 | 65.4% |
| Alcohol Use Disorder | 25 | 68% |
| Anorexia Nervosa | 25 | 56% |
| Major Depressive Disorder | 25 | 56% |
| Substance Use Disorder | 24 | 50% |
| ADHD | 24 | 58.3% |
| Bipolar Disorder | 23 | 69.6% |
| Anxiety Disorder | 16 | 87.5% |
| Obsessive-compulsive Disorder | 15 | 80% |
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services (ASAM level 2.5) received from 2/27/23-3/20/23 and/or intensive outpatient program (IOP) services (ASAM level 2.1) received from 3/21/23-forward. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 2.5 criteria for PHP services received from 2/27/23-3/20/23.
Nature of Statutory Criteria/Case Summary: Patient has requested reimbursement for residential treatment center (RTC) services & partial hospitalization program (PHP) services. The AACAP & AACP have unified the CALOCUS & CASII into a single instrument, the CALOCUS-CASII. This instrument is a standardized tool used to determine the intensity of services needed for children & adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical &/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use & psychiatric conditions; (4) recovery environment (a. stressors & b. supports); (5) resiliency & response to services; & (6) engagement. The composite score is then used to determine LOC needed.
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 patient has requested reimbursement for partial hospitalization 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.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Program, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY