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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for intensive outpatient program (IOP)  services, 4 hours per day, 4 days a week. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment.With regard to risk of harm, the records support a score of 2. The patient had some potential for risk of harm due a history of an eating disorder and symptoms of anxiety and depression. The patient appears at continued risk for decompensation without a structured program given her struggles with purging and ruminations around food and body image in general. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to continued restricting and purging behavior, leading to a recent hospitalization, compromising her relationships. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to symptoms of depression, anxiety, and an eating disorder. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to her father bringing up residential care as a possibility, preparations to leave for college, tensions with her boyfriend, and everyday food exposures that triggered anxious and depressive ruminative thinking patterns and the patients eating disorder.  With regard to level of support of the recovery environment, the records support a score of 2 due to support from the patients parents and boyfriend. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment due to a recent hospitalization and continued struggles with negative and maladaptive thinking patterns and purging behaviors. With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrates overall motivation, although she continued to struggle with negative and ruminative thought patterns around eating. Thus, the patient has a total score of 18. In this case, the recommended level of care is high intensity community-based services. This is consistent with the level of care that the patient is receiving in intensive outpatient program. In this patients case, IOP level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services 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 services, 4 hours per day, 4 days a week are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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.