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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intensive outpatient program level of care services with Exposure Response Prevention (ERP) therapy and Equine Activity Treatment (EAT) or residential treatment center level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in order to objectively determine the appropriate level of care for the patient, the Child and Adolescent Level of Care Utilization System (CALOCUS) was utilized. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2. When upset, the patient has had episodes of suicidal ideation with no intent. The most recent documentation indicated that the patient did not have any current suicidal ideation. With regards to functional status, the records support a score of 3. The patient has moderate functional impairment. In terms of comorbidity, the records support a score of 3. The patient has comorbidities of attention deficit/hyperactivity disorder, obsessive-compulsive disorder, oppositional defiant disorder, unspecified anxiety, and depression. Per the records, he does not have any medical problems which require 24-hour monitoring. With regards to environmental stress, the records support a score of 3. The patient has a moderately stressful environment. There was a significant disruption of the family milieu when the patients father died two years ago. In terms of environmental support, the records support a score of 2. The patients mother is supportive of the patient. With regards to resiliency, the records support a score of 3. The patient will have periods of modest improvement and periods of worsening of his symptoms. Treatment has been interrupted due to noncompliance and provider changes. In terms of acceptance and engagement, the records support a score of 3. Thus, the documentation supports a composite score of 19. Based on these criteria, the patient meets criteria for an intensive outpatient program. He does not meet criteria for a residential treatment center placement. Regarding EAT, equinerelated treatments for mental disorders lack empirical support. This type of treatment is not medically necessary for the treatment of the patient. However, ERP therapy is considered the gold standard for the treatment of obsessive-compulsive disorder. Therefore, intensive outpatient program level of care services with ERP therapy is medically necessary for the treatment of this patient. However, the medical necessity of EAT or residential treatment center level of care services has not been established. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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.