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 eating disorder intensive outpatient program (IOP) treatment for eight weeks, four days per week, for three and a half hours per day. 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. Applying the CALOCUS framework, this patient meets the criteria for IOP services.For dimension 1, the patient is at significant risk of harm (score 3) due to a history of engaging in dietary restriction, purging, and self-harm behaviors. Although the patient has been compliant with her meal plan and has been eating 100% of her meals, she has experienced episodes of intermittent purging, which have adversely affected her vital signs. The patient denies suicidal ideation and does not have a history of suicide attempt. However, she does have regular urges to cut herself and has cut herself recently. The records document that the patient has periods of inability to care for self and/or maintain physical safety in developmentally appropriate ways. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) since her recent gains including stabilization in weight and eating disorder symptoms were achieved while participating in an eating disorder treatment program. There is support that any recent gains and/or stabilization in functioning have been achieved while participating in treatment in a structured, protected, and/or enriched service. For dimension 3, the patient has significant comorbidities (score 3) considering her diagnoses of anorexia nervosa, depression, and anxiety. The patient was also noted to be engaging in purging behaviors. Medical sequelae of the patients eating disorder have included orthostasis and dizziness. Medical conditions are present that may adversely affect, or be affected by, the presenting condition. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The patients father had heart surgery earlier in this year and her mother is stressed about possibly losing her job due to having to transport patient to and from treatment. The records document somewhat inadequate material resources or threat of loss of resources due to parental underemployment, separation, or other factors. For dimension 4B, the patients recovery environment is supportive (score 2). The patient has stated that she is better able to comply with her meal plan at home than in a treatment facility. The patients mother provides mealtime support. The records also indicate that the patient confides in her mother when she has purged or self-harmed, and that her mother responds by providing additional support and oversight. The patients family is willing and able to participate in treatment if requested to do so and has capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). Previous treatment has included outpatient therapy, IOP, PHP, and RTC levels of care. In addition, the patient has been hospitalized twice, including once in 2020 for weight loss, malnutrition, and bradycardia. A second hospital admission occurred in 2021, again for malnutrition. During this hospitalization, she was placed on a nasogastric tube for 10 days and this hospitalization  was followed by admission to RTC before she was stepped down to PHP. This indicates that previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure to treatment. For dimension 6, the patient has been constructive in treatment (score 2) due to her ability to complete  100% of her meals without need for replacement and expression of strong intrinsic motivation to recover and return to her life. Although the patient endorsed some guilt and anxiety associated with eating and body image disturbance, she reported a readiness to step down. This is most consistent with constructive engagement in treatment. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 19, which is consistent with Level 3 high intensity community-based services. Moreover, the requested IOP services 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 requested eating disorder IOP treatment for eight weeks, four days per week, for three and a half hours per day is medically necessary for treatment of the 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.