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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient psychiatric (IOP) treatment for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. As of the date in dispute, the patients risk of harm score is two (2), some risk of harm. The patient does not have a history of suicide attempts. The patient has chronic suicidal ideation. He threatened to harm himself; however, documentation did not state that this was considered a serious threat. The patient was not taken to a hospital and emergency services were not notified. The attempt was an expression of his chronic suicidal ideation. The patients functional status score is three (3), moderate functional impairment. Due to the patients autism spectrum disorder, the patient struggles socially with his peers. The patient has chronic severe deficits in his interpersonal relationships. The patient has a history of refusing to go to school.  The patient has a history of familial conflicts with parents. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of autism spectrum disorder, major depressive disorder, mixed obsessional disorder, ADHD, and anxiety. The patient does not have any medical problems which required 24-hour monitoring. The patients recovery environmental stress score is two (2), mildly stressful environment. The patient has a supportive family. Expectations for performance at home and in school work create discomfort. The patients environmental support score is two (2), supportive environment. The patient has supportive parents who are willing to participate in treatment. The patients resiliency score is two (2), significant response to treatment. The patient has made improvements with IOP treatment. The patient reported that he improved with his ability to handle money. The documentation indicates that he was open to communication to others and his providers. The patients acceptance and engagement score is two (2), constructive. The patient has been cooperative with staff for the majority of the time. He will participate in groups and has made progress with sharing his emotions and experiences. Based on these criteria, the patient has a composite score of 16 and meets criteria for outpatient treatment and could safely and effectively be treated in a less restrictive environment. The patient continued to need treatment for his autism spectrum disorder, major depressive disorder, mixed obsessional disorder, ADHD, and anxiety, but this could be accomplished at a less restrictive environment. Therefore, the IOP treatment services provided were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.