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 the intensive outpatient program (IOP) services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found the progress notes do not reflect severe emotional outbursts or other issues that would warrant any intensive type of treatment. The progress notes indicate the patient was cooperative in treatment. His family was engaged in treatment and it appears that they were experiencing an amicable relationship. The progress notes do not reflect arguments or outburst during family therapy sessions. The progress notes do not indicate that the patient had any serious mood symptoms or psychosis. The progress notes indicate the patient was not receiving any type of substance abuse treatment prior to his enrollment in the IOP. He was not experiencing self-harm according to the progress notes. He has a history of a suicide attempt a few years prior to his IOP admission. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS), this patient had no risk of harm (score 1) due to the patients lack of current self-harm ideation and his functional impairment was minimal (score 1) with some deterioration and expected level of functioning in relationships with family. The patient has no co-morbidity (score 1) as he does not have active serious medical problems or psychiatric symptoms. The patients recovery environment is mildly stressful (score 2) as the patient has issues with family relationships family but has a stable housing situation and his level of support is highly supportive (score 1) as his family is actively involved in treatment and attend family therapy sessions on a regular basis. The patient has demonstrated recent treatment progress (score 2) demonstrating significant improvement with treatment. The patient has been constructive in treatment (score 2) as he is noted to participate actively in therapy and his parents have been constructive in treatment (score 2) and are noted to work actively and constructively with patients providers. This gives the patients presentation a composite score of 12 which correlates with outpatient services.  As noted by the American Academy of Child and Adolescent Psychiatry (AACAP), children and adolescents should be treated in the least restrictive setting possible to maintain and foster natural supports. In addition, the current literature indicates that effective self-harm reduction can occur with therapy available on an outpatient basis such as dialectical behavioral therapy. All told, the IOP services provided by Insight were not and are not medically necessary for treatment of this patients behavioral health issues. 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.