Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for Intensive Outpatient Program (IOP) level of care.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for children needing mental health treatment. In this case, in terms of risk of harm, the records support a score of 2, which corresponds with some risk of harm. This is due to the patients suicidal ideation with no intent or plan, his recent impulsive overdose on antidepressants that was not reported to be suicidal in intent, and his recent substance use. With regards to functional status, the records support a score of 3, which reflects moderate functional impairment, due to the patients withdrawn behavior with staff in the program and his stabilization in the context of the IOP program. In terms of comorbidity, the records support a score of 2. The patient had minor co-morbidity, due to his combination of substance use, depression, ADHD, and anxiety symptoms. With regards to the level of stress of the recovery environment, the records support a score of 2, which corresponds with a mildly stressful environment. This is due to the patients potential for exposure to substance use and his struggles to meet expectations in the IOP program and at home. In terms of the level of support of the recovery environment, the records support a score of 2, as the patients mother participated in IOP treatment, thereby providing a supportive environment. With regards to resiliency and treatment history, the records support a score of 3, which reflects moderate or equivocal resiliency and/or response to treatment. This is due to the patients lack of progress at a lower level of care and his limited ability to follow through with treatment recommendations. In terms of acceptance and engagement of the patient, the records support a score of 3. The patients score reflects that the patient is incompletely engaged and has difficulty accepting responsibility for his behavior. Thus, the patient had a composite score of 17. Using the CALOCUS level of care determination grid, the recommended level of care is Level Three: High Intensity Community-Based Services. CALOCUS level of care definitions and utilization criteria state that this level of care generally is appropriate for children and adolescents who need more intensive outpatient treatment. Treatment may be needed several times per week, with daily supervision provided by the family or facility staff. Minimal oversight should be required for this level of service and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. In this case, the IOP program that the patient is attending provides Level Three services, and the patient continues to need this level of care. Therefore, the requested continued Intensive Outpatient Program (IOP) level of care was and is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were and are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty 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.