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. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, the patient met the criteria for the IOP services. For dimension 1, the patient has been at significant risk of harm (score 3) due to a history of suicidal ideation and self-harm. In the past, the patient held a knife to her throat with the intention of ending her life. The records document no active suicidal ideation, but extreme distress and/or a history of suicidal behavior. For dimension 2, the patient has demonstrated mild functional impairment (score 2) given her ability to function academically but struggles socially. There is some evidence of minor failures of function in any of several areas of living: school, family, peers. These periodic or momentary failures are time limited. For dimension 3, the patient has minor co-occurrence (score 2) given her struggles with insomnia, but she is sleeping well with trazodone. On review of the records, a self-limited medical condition is present that is not immediately threatening or debilitating and have no impact on the presenting condition and are not affected by it. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The records indicate that the patients father struggles to manage his anger and he tries to control situations. The provider noted that the patients mother attempts to mask her emotions and tries to problem solve for the patient. There is evidence of disruption of family milieu. For dimension 4B, the patients recovery environment has been supportive (score 2). The provider charted that the patients parents appear supportive. The patient indicated that she has two good friends who are also supportive. The patients primary caretakers are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has shown moderate or equivocal resiliency and response to services (score 3). Prior treatment has included outpatient psychiatric care and one session of outpatient therapy after which she was referred to a higher level of care. The records suggest that the patient has demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development. The records document developmental pressures and life changes have caused some deterioration in function. For dimension 6, the patient has exhibited adequate engagement in treatment (score 2). The provider noted that the patient has participated in group, individual, and family therapies. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 17, which is consistent with Level 3 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. The records indicate that the frequency of services have gradually tapered over time to allow the patient to practice skills learned. For these reasons, the IOP services were and are medically necessary for the 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.