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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) 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. The six dimensions include: (1) risk of harm; (2) functional status; (3) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, the patient meets the criteria for the IOP services. For dimension 1, the patient has been at some risk of harm (score 2). The records document that the patient has not endorsed suicidal or homicidal ideation since IOP admission. The patient has no history of attempting suicide. The patient does have a history of angry outbursts, which frighten his family members. There is indication or report of occasional impulsivity and/or some physically aggressive impulses with minimal consequences for self or others. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) due to struggles with motivation, which manifested as failure to complete schoolwork and household chores. The patient struggles in his relationship with family members due to his severe anger outbursts. The patient has difficulty keeping friends and overeats to compensate for lack of friendships. The patient has conflicted, withdrawn, or otherwise troubled relationships with peers, adults, and family, but without episodes of physical aggression. For dimension 3, the patient has minor co-occurrence (score 2) given his obesity and struggles with overeating. The patients weight is a concern and can contribute to poor self-esteem and anxiety. There is evidence of self-limited medical conditions that are not immediately threatening or debilitating and that have no impact on the presenting condition and are not affected by it. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The provider noted that the patient has a conflictual relationship with his brother, and they frequently fight. The patients father has difficulty managing his anger and can act aggressively towards the patient. There is documentation of disruption of family and social milieu. For dimension 4B, the patients recovery environment is supportive (score 2). The records indicate that the patients parents are not aligned in how they parent him and disagree on discipline. The patient feels a lack of connection and support from his family and reports feeling judged by his brother. However, the patients family members are willing and able to participate in treatment and have the capacity to effect needed changes. For dimension 5, the patient has shown moderate or equivocal resiliency and response to treatment (score 3). Prior treatment has included a brief course of online therapy, which the patient discontinued after three sessions, and a brief hospitalization. The patient has demonstrated limited ability to follow through with treatment recommendations. For dimension 6, the patient has exhibited adequate engagement (score 2). The records document that the patient has participated in group, individual, and family therapies. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 17, which is consistent with Level 3 high intensity community-based services. In addition, the IOP services were and are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the IOP services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for evaluation of 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.