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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patients risk of harm score is two (2), some risk of harm. The patient has no prior history of suicide attempts or psychiatric hospitalizations. Last summer, the patient had episodes of self-harm in which the patient would superficially cut the wrists, fingers and forearms. The patient has not had any self-injuries since admittance in the IOP. The patients functional status score is three (3), moderate functional impairment. The patient has shown improvement since starting IOP. However, the patient continues to struggle with depression and anxiety and having interpersonal conflicts with the patients father. The patient has a history of missing school and falling grades. The patient is in the process of bringing grades back up. The patients co-morbidity score is two (2), minor co-morbidity. The patient has a co-morbidity of major depressive disorder and generalized anxiety disorder. The patient does not have any serious medical problems. The patients recovery environmental stress score is two (2), mildly stressful environment. The patient has a supportive mother. The patient reports that she has interpersonal conflicts with the patients father. The patients environmental support score is two (2), supportive environment. The patient has a supportive mother who is willing to participate in treatment. The patients resiliency score is two (2), significant response to treatment. The patient reports having significant improvements in the patients symptoms since admission to IOP. The patients acceptance and engagement score is two (2), constructive. The patient is cooperative with staff. The patient is motivated for change. The patient will passively cooperate in treatment planning and treatment. Based on these criteria, the patient has a composite score of 15 and would meet criteria for outpatient services. The patient continues to need treatment for major depressive disorder and generalized anxiety disorder, but this could have been accomplished in a less restrictive environment. Final Result: The reviewer determined that the services at issue were not and are 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 expertise 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.