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

Nature of Statutory Criteria/ Case Summary:  The enrollee has cannabis use disorder, oppositional defiant disorder, generalized anxiety disorder, and parent-child relational problems. Previous treatment history included individual sessions with a family therapist and residential treatment for two weeks. The enrollee subsequently entered intensive outpatient program (IOP) services. Goals were mood stabilization, by decreasing anxiety symptoms from several times daily to a few times weekly, abstinence from substances, improving attention/concentration and learning to modulate impulsive behavior. Enrollee participated in group, individual, and multifamily sessions.  The plan was for the enrollee to be continually assessed for his appropriateness to transition to a lower level of care, with the hopes that his mood would stabilize. However, continued to exhibit significant depressed and anxious affect during this review period. He continued to struggle with destructive and impulsive behaviors, as evidenced by relapses and fighting during group. Enrollee showed some ability to engage in group discussion at times but required continued participation in the program because of lack of progress toward goals. Enrollee was not worried about the consequences of using cannabis, did not know how to stay sober, and felt sad for disappointing his parents. The enrollee continued to relapse and the records support the necessity for all of the intensive outpatient program level of care services. CALOCUS assessment tool for level of care indicates for risk of harm, the enrollees score is 2, because there was no concern for suicidal or homicidal ideation, but the enrollee had poor judgment and was acting out. For functional status, the enrollees score is 3, due to the enrollee being asked to leave high school and demonstrating poor relationships. For comorbidity, the enrollees score is 3, due to diagnoses of cannabis use disorder, conduct disorder, generalized anxiety disorder, and hepatitis C. For recovery environment level of stress, the enrollees score is 3, due to frequent relapsing and an inability to say no to his peers. For recovery environment level of support, the enrollees score is 3, due to leaving work and living at a friends house. For treatment and recovery history, the enrollees score is 4, due to his being relatively new to treatment. For engagement and recovery status, the enrollees score is 3, due to a previous history of relapse. Enrollee is engaging in individual and family therapy and his family is involved. The enrollees composite LOCUS score is 21, which correlates with intensive outpatient program level of care services.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child & 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 similar medical condition.