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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services, which specifically include any or all of the below listed services: (1) one hour a week of in-person group therapy for the patients parents only, (2) two hours a week of in-person multi-family therapy services (including the patient, parents of the patient, siblings of the patient, grandparents of the patient, any other family members who are actively involved in the patients life, and other patients in the IOP and their parents), and (3) one hour a week of in-person individual family therapy (patient, parents, and sibling). Findings:  The physician reviewer found that 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, this patient meets the criteria for IOP services.With regard to risk of harm, the records support a score of 2. The patient has some risk of harm, due to some self-harm, without a history of suicide attempts or suicidal ideation.  In terms of functional status, the records support a score of 3. The documentation notes moderate functional impairment as the patient is argumentative, irritable, oppositional, and defiant. She is easily frustrated and has difficulty managing her anger. She is attending school and participating in extracurricular activities. With regard to comorbidity, the records support a score of 1. The patient does not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a moderately stressful environment due to a conflictual relationship with family members, struggles with parental expectations, and her own emotional reactivity, leading to the family arguing and blaming one another. With regard to level of support of the recovery environment, the records support a score of 3 due to the parents participation in treatment. However, the patients parents are also noted as struggling with their own frustrations and having difficulties with parental consistency and working as a team. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment as prior treatment has included outpatient psychotherapy and psychiatric treatment, including psychotropic medication, and a PHP. With regard to treatment acceptance and engagement, the records support a score of 3. The patient struggles with oppositionality and distractibility during therapy sessions and is noted as having limited insight. 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 was and is receiving at the IOP. In this patients case, IOP level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and 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, which specifically include any or all of the below listed services: (1) one hour a week of in-person group therapy for the patients parents only, (2) two hours a week of in-person multi-family therapy services (including the patient, parents of the patient, siblings of the patient, grandparents of the patient, any other family members who are actively involved in the patients life, and other patients in the IOP and their parents), and (3) one hour a week of in-person individual family therapy (patient, parents, and sibling), 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 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.