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 program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing 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. This patient presents with no risk of harm (score 1) due to a lack of current self-harm ideation. He has not expressed any suicidal or homicidal ideation or psychosis. The patient has not been aggressive with anyone in the program or exhibited emotional or physical outbursts during the IOP sessions. The patient has experienced minimal deterioration in functioning (score 1) with some difficulties in relationships with family, but overall he has demonstrated appropriate daily functioning. The patient has no documented comorbidity (score 1) without any documented serious active medical problems or history of substance abuse. The patients recovery environment is mildly stressful (score 2) as the patient has issues with family relationships, but has a stable housing situation. The patients recovery environment is highly supportive (score 1) as the patients father is actively involved in treatment and attends family therapy sessions on a regular basis. The patient has a lack of documented recent treatment (score 2). The patient has demonstrated an overall positive behavioral improvement and a relatively stable mood throughout the IOP sessions. The patient is described as constructive in treatment (score 2) as he has participated in therapy and been cooperative. The progress notes indicate the patient has made substantial behavioral improvement over the first two months of IOP. In addition, the patients father has worked actively and constructively with the patients providers (score 2). This gives the patients presentation a composite score of 12, which correlates with recovery management. Given these findings, the patients presentation does not meet the criteria for IOP level of care. Accordingly, the IOP services 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 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.