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. For dimension 1, the patient has been at some risk of harm (score 2) due to a history of suicidal ideation and homicidal ideation, along with a history of psychiatric hospitalization and self-harm. The patient has exhibited ongoing behaviors concerning for reactivity and impulsivity. There are ongoing symptoms of anxiety and depression with difficulties with communication and problem solving skills when in conflict. The patient also has a history of restricting food and is vulnerable towards relapse. The records document a past history of fleeting suicidal or homicidal thoughts with no current ideation, plan, or intention and no significant distress. Also noted are infrequent, brief lapses in the ability to care for self and use environment for safety. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given the patients persistent mood symptoms such as frequent crying and anger, resulting with difficulties with school attendance and IOP treatment. In addition, the patient has continued to demonstrate chronic and variably severe deficits in interpersonal relationships, although with  some ability to engage in socially constructive activities, and some ability to maintain responsibilities. There is documentation that the patient has 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 significant co-occurrences (score 3) due to blindness in the left eye secondary to retinal detachment at birth. The patient also reports a history of chronic depression, anxiety and a significant eating disorder. Overall, the patient has psychiatric signs and symptoms that persist in the absence of stress, are moderately debilitating, and adversely affect the presenting condition. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The patient reports having chronic problems with their family. There appears to be perceptions of role expectations that exceed the patients age, status, and developmental level. The patient has not been able to communicate effectively with their family and they report concerns of criticism from family members. For dimension 4B, the patients recovery environment provides limited support (score 3) given the continued need for family intervention/therapy. The patient reports ongoing perceptions of being judged by family. The patients family has limited ability to respond appropriately to the patients developmental needs and/or problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient has exhibited moderate resiliency and response to services (score 3). The records document that the patients recovery has been maintained for moderate periods of time, but only with strong professional or peer supports or in structured settings such as at IOP. For dimension 6, the patient has adequately engaged in treatment (score 2) since the patient has demonstrated some involvement in services and has made some improvement. The providers charted that the patient passively cooperates in treatment planning and services. These findings give the patient a composite score of 19, which is consistent with high intensity community-based services. Moreover, 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. Given these findings, the IOP services were and are medically necessary for 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.