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. Findings:  The physician reviewer found that The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, the patient meets the criteria for the IOP services. For dimension 1, the patient has been at significant risk of harm (score 3) due to a history of suicidal ideation, suicide attempt, and self-harm. During the current IOP admission, the patients mother reported that the patient was suicidal. The records document no active suicidal or homicidal ideation, but extreme distress and/or a history of suicidal behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3). The patient attends school, but she has a conflictual relationship with her mother and father, including disagreement about where the patient will attend school. The patient has shown chronic and/or variably severe deficits in interpersonal relationships, but with ability to engage in socially constructive activities, and ability to maintain responsibilities. For dimension 3, the patient has no co-occurrence (score 1). The available records do not document any medical conditions or substance use issues. The patient has no evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The provider noted that the patients parents are divorced and have an antagonistic relationship. The patients older sister was hospitalized following a suicide attempt just prior to the patients admission. The patient and her parents have a conflictual relationship. There is report of disruption of family milieu. For dimension 4B, the patients recovery environment has provided limited support (score 3). The patient reports feeling unvalued, unheard, and unsupported by her mother. The patient has stated that she is afraid to speak to her father about certain matters. The patient indicated that she is supported by friends who attend her current school. The patients family or primary caretakers demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient has exhibited significant resiliency and response to services (score 2). Prior treatment has included outpatient treatment and a brief hospitalization. The records suggest that the patient has demonstrated an average ability to deal with stressors and maintain developmental progress. For dimension 6, the patients parents have shown minimal engagement in treatment (score 4). The provider noted that the patients parents participated in family therapy and appeared to have been receptive to the providers feedback. The parental engagement appears adequate but both parents struggle to connect emotionally with the patient. The patients parents appear accepting of the patients need to change but are unable or unwilling to consider the need for any changes in other family members. These findings give the patient a composite score of 19, which is consistent with Level 3 high intensity community-based services. In addition, the IOP services were and are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the IOP services were and are medically necessary for the 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.