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

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) developmental, medical, substance use 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.For dimension 1, the patient has been at low risk of harm (score 1) since he did not demonstrate any evidence of suicidal ideation or homicidal ideation in his sessions. There is no indication of current suicidal or homicidal thoughts or impulses, with no significant distress, and no history of suicidal or homicidal ideation. For dimension 2, the patient has demonstrated mild functional impairment (score 2) given his ability to participate in group, individual therapy, and educational work, as well as family therapy and family interactions. He continues to struggle with interactions with family and adult staff. He has been able to perform adequate self-care. There is some evidence of minor failures of function in any of several areas of living including school, family, and peers. For dimension 3, the patient has minor comorbidities (score 2) due to his diagnoses of disruptive mood dysregulation disorder, attention-deficit/hyperactivity disorder (ADHD), and fetal alcohol syndrome. He used an opiate product while in treatment as evidenced by a urine drug screen positive for morphine. The records document occasional, self-limited episodes of substance use are present that show no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment is moderately stressful (score 3) considering his ongoing conflict with his father and stepmother. There is disruption of family and social milieu as the patients stepmother indicated that she does not want the patient to return home. For dimension 4B, the patients recovery environment provides limited support (score 3) as his family or primary caretakers demonstrate only partial ability to make necessary changes during treatment. His family placed him into treatment and participated in family therapy but were unwilling to change some of their behaviors. The patient is unlikely to return home after completion of treatment. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to treatment (score 3). The records document that he has been compliant with his medication and relating his experiences to his providers. He showed attempts to use coping skills learned in therapy and became resistant or disillusioned after about one week of being told that he could not return home. The patient has demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development. For dimension 6, the patient has been incompletely engaged in treatment (score 3) due to ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. The records suggest that the treatment team planned to place the patient in a boarding environment since he was unable to return home. These findings give the patient a composite score of 17, which is consistent with Level 3, high intensity community-based services. For these reasons, the IOP services were and are medically necessary for treatment of this patient.