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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested authorization and coverage for in-home family treatment (IIFT) program services.At issue is whether in-home family treatment (IIFT) program services, including: 24-hour video monitoring in the home setting and utilization of clips of negative interactions for therapeutic and family therapy purposes; one hour per week of individual therapy in the office setting (code 90837); one hour per week of individual therapy in the home setting (code 90837); one hour per week of family therapy with patient present in the home setting (code 90847); and one hour per week of family therapy without the patient present in the home setting (code 90846) are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.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. Using CALOCUS, 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) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, the patient has not met the criteria for IIFT program services. With regard to risk of harm, the records support a score of 4. The patient engages in self-harm behaviors including cutting, burning self, and punching objects. The patient has a history of engaging in risky and potentially dangerous activities by having on-line conversations with adult male strangers, turning off her smartphone monitoring app, and lying to her parents. Police have had to be called to the home twice due to her locking herself in the bathroom and engaging in self-harm behaviors. The patient endorses passive suicidal ideation following arguments with her family. Given the patients young age, increasing and escalating behaviors which place her in harms way and may lead to sexual victimization, coupled with her lack of insight and impulsivity, her potential risk of harm is serious.In terms of functional status, the records support a score of 3. The patient exhibits moderate to severe functional impairment. The patient is described as withdrawn and isolative. The patient escalates quickly when limits are set and becomes angry and rages at her parents. She has stolen her parents credit card information and used it to spend hundreds of dollars making on-line purchases which she then lied about.With regard to comorbidity, the records support a score of 3. The patient is reported to have disordered eating and is being closely followed by her pediatrician due to dietary restriction which has led to weight loss and vital sign instability. Malnutrition can contribute to mood instability and emotion dysregulation. The patient also suffers from chronic migraine headaches. In terms of level of stress of the recovery environment, the records support a score of 4.The patients recovery environment is highly stressful, in part due to patients frequent lying and frequent arguments during which she quickly escalates and then engages in self-harm. Police have been called to the home twice as a result of her threatening and self-harming behaviors. She becomes explosive whenever parents attempt to set a limit with her or confront her about her problematic behaviors. The family has moved twice in the last year and had to give up the family dog for adoption which was upsetting to patient. With regard to level of support of the recovery environment, the records support a score of 3. The patients recovery environment appears to be limited in the support provided. Records indicate that mother has frequently told providers that she does not know what else to do to manage patients escalating behaviors. In-home therapy has been disrupted due to changes in therapists, suggesting that community resources are inconsistent and may be limited. Parents have called police twice suggesting that they are unable or do not have the skill set to manage their childs problematic behaviors without enlisting the assistance of law enforcement.In terms of resiliency and treatment history, the records support a score of 3. Prior treatment includes outpatient treatment, an intensive outpatient program, and intensive in-home therapy. She has been taken to the emergency department once for self-harm. Patient has been offered a partial hospital program but reportedly refused to attend. Patient has refused to engage in treatment when IOP and/or PHP was recommended. Previous treatment at lower levels of care has not been successful in relief of symptoms.With regard to treatment acceptance and engagement, the records support a score of 4. The youth is not engaged in treatment and refuses to participate in IOP or PHP. Records state that she denies having any current family or peer issues and that the patient views the problem as her parents and does not accept any age-appropriate responsibility for her role in the development, perpetuation, or consequences of her problems. This is consistent with non-collaborative engagement.These findings give the patient a composite score of 24. This is consistent with Level 5 Medically Monitored Residence Based Services. Per CALOCUS, the patients score of 4 for Risk of Harm also supports treatment at the Level 5 Medically Monitored Residence Based Services level of care. In this patients case, IIFT program services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration.