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

The enrollees parent is requesting reimbursement for an intensive outpatient program (IOP). The enrollee has diagnoses of major depressive disorder, recurrent episode, severe; generalized anxiety disorder; cannabis use disorder, severe, in partial remission; parent-child relational problem; oppositional defiant disorder; and personal history of self-harm. The enrollee was re-admitted to an intensive outpatient program because of relapses in self-harming behavior and his desire for ongoing support. The enrollee struggled to invest in his treatment, not feeling connected to his peers and slowly regressing behaviorally. He was non-compliant with home rules and certain treatment goals. He struggled to take responsibility for his actions. The discharge summary indicates the enrollee did not report significant improvement in his mood and his sense of well-being. He did not achieve a significant reduction in anxiety disorder symptoms. The enrollee continued to struggle with compliance to home and treatment rules. His prognosis was poor, as he had been behaviorally regressing and his family had been inconsistent with setting healthy limits at home.    The enrollee was re-admitted into an intensive outpatient program due to self-harm after an accident, but there are no details provided in the record about the accident. Based on the record, which includes a master treatment plan, discharge master treatment plan, group session notes, multifamily session notes and clinical meeting notes, the enrollee was not adequately engaged in his treatment and struggled to take responsibility for his actions. It is indicated his family was not involved in the enrollees care.  A multifamily session note indicates family is not willing to participate.  The enrollee was informed he will be transitioned to outpatient level of care. The records did not demonstrate the patient was at risk of self-harm, had previous self-harming behaviors, suicidal ideations or suicide attempts.  There is no information about risk taking behaviors that may directly result in self-harm or whether the enrollee is a potential victim of abuse. The records did not provide evidence of the enrollees functional status, including his ability to perform activities of daily living, and his eating and sleeping patterns. There is no specific information about his school situation or alternative school placement. The record indicates the enrollee is abstinent from the use of cannabis without any specific details, including history of use. The records do not include the enrollees medical history, medication management treatment for major depressive disorder, and/or generalized anxiety disorder, including but not limited to ever being seen by a psychiatrist or primary care provider.  There is insufficient evidence of any past inpatient treatment due to mental health difficulties and medication management trials with response to treatment, if any.  In summary, the records did not support the requested level of care during the time period in question.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.