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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Intensive Outpatient Program services.The submitted documentation does not support that Intensive Outpatient Program services were medically necessary. During the period in issue, the progress notes indicate that the patient was cooperative in treatment. He was not aggressive with anyone in the program, and he did not exhibit emotional or physical outbursts during the IOP sessions. It appears that his mood was relatively stable throughout his sessions. While he had some minor depression symptoms, he did not express any active suicidal or homicidal ideation or psychosis. The records do not provide any indication as to why his services could not be provided on an outpatient basis as his treatment goals appeared to be amenable to family therapy and outpatient counselling.Medical literature provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 1. This is due to the patients lack of self-harm ideation during the period in issue. With regards to functional status, the records support a score of 1. While the patient had deterioration in his expected level of functioning in relationships with family, he generally appeared functional day to day. In terms of comorbidity, the records support a score of 1. The patient did not have any active serious medical problems or active substance use effecting symptoms during the period in issue. With regards to level of stress of the recovery environment, the records support a score of 2. The patient had mild issues with family relationships but had a stable housing situation. In terms of level of support of the recovery environment, the records support a score of 1. The patient had a highly supportive recovery environment, as the patients mother was actively involved in treatment and attended family therapy sessions on a regular basis. With regards to resiliency and treatment history, the records support a score of 2. This is due to a lack of documented recent treatment, but it is also noted that overall the patients behaviors improved significantly during the IOP sessions. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy, appeared to be motivated for treatment, and had strong relationships with therapists. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients mother worked actively and constructively with clinicians. Thus, the patient had a composite score of 12. This score correlates with a treatment intensity level of Recovery Management. Therefore, Intensive Outpatient Program services provided during the period in issue were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.