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 mental health intensive outpatient program (IOP) services provided four times per week. 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. Applying CALOCUS, this patient meets the criteria for IOP level of care services four times per week. The patient has been at significant risk of harm (score 3) due to impulsivity and excessive use of substances. The patient has demonstrated moderate functional impairment (score 3) as he has conflicted relationships with his family and has made threats toward his peers. Recently, he has shown gains achieved in the context of a structured setting. The patient has significant comorbidities (score 3) including substance use, attention-deficit/hyperactivity disorder (ADHD) and depression, as well as Tourettes syndrome. The patients recovery environment is minimally stressful (score 2) due to a recent transition back to the public school environment after participating in alternative schooling. The patients recovery environment is supportive (score 2) as his parents have been involved with the patients IOP process. The patient has exhibited poor response to prior treatment (score 4) with continued substance use and acting out behaviors despite intensive and extensive treatment in several different programs. The patient has been incompletely engaged in treatment (score 3). The records document that the patient has shown difficulty accepting responsibility for his behaviors and his inappropriate behaviors in IOP. This gives the patient a composite score of 20, which is consistent with medically monitored community based services. This is consistent with the level of care provided by the IOP program, as this program offers evening and weekend support for patients. All told, mental health IOP services four times per week were and are medically necessary for 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.