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 in-home family treatment (IIFT) comprised of: 24-hour video monitoring in home setting and utilization of clips of negative interactions for therapeutic and family therapy purposes; one hour weekly individual therapy in the office setting; one hour weekly individual therapy in the home setting; one hour weekly family therapy with the enrollee present in the home setting; and one hour weekly family therapy without the enrollee present in the home setting, for six to nine months with a reduction in hours as the enrollees conditions improves. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. 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) medical, addictive 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.Based on CALOCUS criteria, this patient meets the criteria for residential treatment. The patient is a serious risk of harm to others (score 4) as evidenced by the patient pulling a knife on his father in the home, getting into altercations with other peers, threatening to harm others, and breaking his hand by punching a police car. The patient has demonstrated serious functional impairment (score 4) given his inability to participate in schooling as well as his strained relationships with his family, peers, and the community. The patient has significant comorbidities (score 3) considering the presence of command auditory hallucinations, substance use issues, as well as broken hand that was self-inflicted. His recovery environment is moderately stressful (score 3) as evidenced by reports of multiple altercations with peers requiring police involvement, availability of cannabis within his environment, and being on house arrest. The patients recovery environment is supportive (score 2) due to the ongoing support of his family and treatment team. The patient has shown poor resiliency and response to treatment (score 4) based on his history of ongoing outpatient treatment, residential treatment, and psychiatric hospitalization. The patient has been adversarial (score 4) rather than accepting and engaged in treatment. The patient continues to exhibit ongoing behavioral issues and poor decision-making such as his insistence on continuing to smoke cannabis despite his symptoms. The patients parents have been constructive with the patients treatment (score 2) despite multiple difficulties and setbacks with his behavior. This gives the patient a composite score of 26, which meets the criteria for medically monitored or medically managed residence based services, such as RTC. However, his parents are requesting a lower level of care in an effort to meet the patients needs within the home and community. The treatment components of IIFT are close to multisystemic therapy. Studies of multisystemic therapy and IIFT report and chance of response, and recovery for the patient without requiring treatment within an RTC. Therefore, IIFT comprised of: 24-hour video monitoring in the home setting and utilization of clips of negative interactions for therapeutic and family therapy purposes; one hour weekly individual therapy in the office setting; one hour weekly individual therapy in the home setting; one hour weekly family therapy with the patient present in the home setting; and one hour weekly family therapy without the patient present in the home setting, for six to nine months with a reduction in hours as the patients conditions improves is medically necessary for 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 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.