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. 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) developmental, medical, substance use 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. For dimension 1, the patient is at significant risk of harm (score 3) due to a history of suicidality leading to inpatient hospitalization, as well as impulsivity, including running away from home, and substance use. The patient is does not have current suicidal ideation, but she reports extreme distress and has a history of suicidal behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her conflict with her parents and social isolation. The patient reported difficulties with school and sleep. For dimension 3, the patient has significant comorbidities (score 3) considering her diagnoses of depression and oppositional-defiant disorder, as well as her recent substance abuse. The patient has a history of substance abuse with significant adverse effect on functioning and the presenting condition. For dimension 4, the patients recovery environment is moderately stressful (score 3) due to her disruption in school and social activities due to the shelter-in-place order. The patient has experienced a disruption of family and social milieu. The patients recovery environment is supportive (score 2) since her to parents have been active participants in her treatment plan. The patients family have been willing and able to participate in treatment, although there have been communication issues to a language barrier. The patient identified that she gets angry when her father makes remarks that it is a womans role to take care of the house. For dimension 5, the patient has exhibited moderate resiliency and response to treatment (score 3). The records report that the patient has shown limited ability to follow through with treatment recommendations. The patient reported that it is difficult for her to wake up on time and she lacks commitment to her responsibilities. For dimension 6, the patient has been incompletely engaged in treatment (score 3) due to her lack of investment in treatment. The provider noted that the patients peers confronted her due to her lack of involvement in treatment and being late for sessions, especially since the transition to online groups. The patient has acknowledged that she needs to become more of a participant. These findings give the patient a composite score of 20, which is consistent with medically monitored community based services, similar to the IOP with wraparound services that have been provided. Per CALOCUS, at this level, reviews should not be required more often than every six weeks for acute care settings such as partial hospital and no more than every three months for extended care services such as wraparound. Given this recommendation, the IOP services were and are medically necessary for 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 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