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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested reimbursement and prospective authorization and coverage for all or any of the intensive outpatient program (IOP) services provided at Insight Treatment Program from 8/03/21, going forward.At issue is whether all or any of the IOP services provided at Insight Treatment Program from 8/03/21, going forward were and are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, 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; (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. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.With regard to risk of harm, the records support a score of 3. The patient has persistent passive suicidal ideation, a relapse with self-harming behavior, and had been restricting food intake. The patient also experienced panic attacks at school and contacted her therapist for support.In terms of functional status, the records support a score of 3. The patient has difficulty communicating with her family, as well as the gains she achieved while participating in the highly structured environment of the IOP program. The patient has had reports of several weeks of food restriction, which demonstrates moderate functional impairment. With regard to comorbidity, the records support a score of 1. The patient does not have reports of substance abuse, medical, or developmental disorders.In terms of level of stress of the recovery environment, the records support a score of 2. The patient has stress and anxiety related to returning to in-person school and navigating social and family relationships as well as academic pressures. With regard to level of support of the recovery environment, the records support a score of 2. The patients parents and siblings are actively participating in treatment, with some struggles related to communication. In terms of resiliency and treatment history, the records support a score of 3. The patient has shown improvement in her time in IOP but continues to struggle with anxiety and panic attacks upon starting school, difficulty communicating with family, and food restriction. The patient relapsed with self-harm as well. With regard to treatment acceptance and engagement, the records support a score of 2. The patient is actively participating in treatment.These findings give the patient a composite score of 16. Per CALOCUS, the recommended level of care is Level Two: Low-Intensity Community-Based Services. At this level of care, treatment intensity ranges from one hour every four weeks, to up to two hours per week. The IOP level of care being requested cannot be justified when the CALOCUS criteria are applied to the clinical records provided. In this patients case, IOP level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the intensive outpatient program (IOP) services provided at Insight Treatment Program from 8/03/21, going forward 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 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.