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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested reimbursement for intensive outpatient (IOP) treatment services from  provided by ROWI Teen & Parent Wellness Center.At issue is whether the IOP treatment services from provided by ROWI Teen & Parent Wellness Center were medically necessary for treatment of the patients mental health or substance use disorder for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care, (ii) clinically appropriate in terms of type, frequency, extent, site, and duration, and (iii) 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.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 3 due to a recent history of drug use, self-harm via cutting, chronic struggles with anxiety with escalating depression, and suicidal ideation. The patient appeared to continue to intermittently struggle with anxiety and depressive symptoms while in IOP treatment.In terms of functional status, the records support a score of 3. The documentation noted moderate impairment. The patients mother indicated that the patient had been overwhelmed in school. The patient has had recent gains in functioning due to participating in treatment in a structured, protected, and/or enriched service.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to anxiety and depressive symptoms with suicidal ideation along with recent substance use that has only been assisted due to use of a highly structured setting.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to potential for exposure to substance use. The patient also had the stressor of expectations for school.With regard to level of support of the recovery environment, the records support a score of 2. The patients family appears willing to support the patient as best as possible, with community resources sufficient to address patients needs.In terms of resiliency and treatment history, the records support a score of 3. The patient had a history of significant struggles with anxiety and depression as well as substance use. Historically, the patient has done poorly with outpatient mental health support, and only appeared to improve significantly at partial hospitalization program (PHP) level of care, and upon completion, transitioning to IOP. With regard to treatment acceptance and engagement, the records support a score of 2 as the patient appeared engaged and motivated while receiving treatment. Thus, the patient has a total score of 18. In this case, the patient has had a history of significant substance use, school failure, anxiety and depression with suicidal ideation. The patient also has a history of self-harm via cutting. In this patients case, IOP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care especially given the patients vulnerability towards relapse and struggles with ongoing fragile mental health. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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 treatment services from provided by ROWI Teen & Parent Wellness Center were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.