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) level of care services. Findings:  The physician reviewer found that 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, this patient met the criteria for IOP services.With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to a history of suicidal ideation without endorsing active suicidal ideation or a history suicide attempts. The patient has a history of self-harm in the past year and of excessive alcohol use.In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment as the patient was attending and participating in IOP and continues to be motivated. The records note minor difficulty in his relationship with his father. With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity, due to the presence of a history of alcohol and cannabis use, including an episode of blacking out while under the influence of alcohol the summer prior to his admission to IOP. The records do not document substance use during IOP, suggesting that the patient has remained abstinent, and his substance use does not appear to show a pattern of escalation. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a moderately stressful environment due his father having a history of anger problems, for which he is in therapy. The patient describes his home life as historically hectic due to extended family members. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment. The patient identifies several close friends and states that he can talk to his friends about anything, indicating that they are supportive. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment as prior treatment has included a brief course of psychotherapy, one psychiatric inpatient hospitalization, and five months of IOP. The patients recovery has been maintained for moderate periods of time, but only with strong professional support/structured setting. With regard to treatment acceptance and engagement, the records support a score of 2. The records indicate that patient has been participating in treatment.  Thus, the patient has a total score of 17. In this case, the recommended level of care is intensive community-based services. This is consistent with IOP level of care. In this patients case, IOP level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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. Therefore, IOP level of care 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 treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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.