Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 16-year-old male with a past psychiatric history of attention deficit/hyperactivity 
disorder, combined presentation, major depressive disorder, single episode, mild, cannabis use 
disorder, moderate or severe, opioid use disorder, moderate or severe, and sedative, hypnotic, 
anxiolytic use disorder, mild. The patients parent has requested reimbursement for adolescent 
substance use disorder IOP single case agreement for services provided from 2/10/22 through 
3/14/22. The physician reviewer found that at issue is whether adolescent substance use disorder 
intensive outpatient program services provided from 2/10/22 through 3/14/22 were medically 
necessary for the treatment of the patients medical condition. Please specify whether or not it 
was medically necessary for the patient to have been seen by the provider 417 Recovery which 
is out of network for his plan. 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 met the criteria for the IOP services provided from 2/10/22 through 
3/14/22. For dimension 1, risk of harm, the records support a score of 2.  This dimension assesses 
potential for harm to self or others, or having harm inflicted upon them. The patient has a history 
of polysubstance use and recently relapsed on cocaine, alcohol, and cannabis. He has a history 
of cutting himself while under the influence of drugs. He denied a history of suicide attempts. For 
dimension 2, functional status, the records support a score of 2. This dimension assesses the 
degree to which a patient is able to fulfill responsibilities within developmental constraints. The 
patient has struggled to stop using cannabis and nicotine while in treatment. Recent gains in 
functioning appear to have occurred while the patient was participating in treatment. He is 
attending school and maintaining good grades. For dimension 3, co-occurring developmental, 
medical,  substance use  and  psychiatric  conditions, the  records  support  a  score  of  3.  This 
dimension assesses the co-existence of disorders across four domains (psychiatric, substance 
use, medical or developmental) that may complicate the course of treatment. The patient 
struggles with both mental health and substance use issues. He continues to experience cravings 
to use drugs and has had positive urine drug tests while in treatment. His substance use has been 
(mostly) arrested due to use of highly structured setting. For dimension 4A, level of stress in the 
recovery environment, the records support a score of 3. This dimension assesses the stressors in 
the environment, social circumstances, and interpersonal relationships. The patient continues to 
be exposed to substance use as he continues to associate with friends who use drugs. The patient 
describes his home environment as pretty chaotic. For dimension 4B, level of support in the 
recovery environment, the records support a score of 3.  This dimension assesses the presence  of family and social support to augment the recovery environment. The patients parents are 
supportive. However, the patients friend group continues to use substances and the patient 
finds it difficult to distance himself from this friend group. The patient is also noted to have 
difficulty reaching out to friends and family for support. For dimension 5, resiliency and response 
to services, the records support a score of 3. This dimension assesses how past experiences with 
treatment and recovery might indicate how the patient might respond in the future. Prior 
treatment has included individual and family therapy, two intensive outpatient programs, a 
partial hospital program, and a brief stay in residential treatment. Overall, he has exhibited 
moderate or equivocal resiliency and/or response to treatment. For dimension 6, engagement of 
the child or adolescent, the records support a score of 3. The child and adolescent sub-dimension 
assesses ability to form therapeutic relationship within developmental constraints. Although the 
patient was engaged in treatment, he struggled with being honest with therapists and parents. 
Concerns about his honesty and willingness were noted. These findings give the patient a 
composite score of 19, which is consistent with Level 3 High Intensity Community Based Services. 
Therefore, intensive outpatient program services provided from 2/10/22 through 3/14/22 were 
medically necessary. However, the medical records fail to demonstrate the medical necessity of 
services provided by the provider 417 Recovery which is out of network for his plan. Although 
it may be preferable for the patient to receive treatment at a program known to him and where 
he is known, appropriate treatment could be provided by any appropriately licensed treatment 
facility specializing  in  adolescent  substance  use  disorders.  Therefore,  it  was not  medically 
necessary for the patient to have been seen by the provider 417 Recovery which is out of 
network for his plan. Thus, an adolescent substance use disorder intensive outpatient program 
single case agreement for services provided from 2/10/22 through 3/14/22 was not medically 
necessary for the treatment of this patient.