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

Findings:  The physician reviewer found that The parent of an enrollee has requested reimbursement and authorization and coverage for Intensive Outpatient Program (IOP) services.At issue in this case is whether the requested Intensive Outpatient Program (IOP) services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A) to treat the patients mental health or substance use disorder. Medically necessary treatment of a mental health or substance use disorder is defined in Health and Safety Code section 1374.72(a)(3)(A) as follows:(A) For purposes of this section, Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.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 Intensive Outpatient Program (IOP) services.With regard to risk of harm, the records support a score of 3. The patient had been experiencing urges to self-harm and use drugs on a daily basis. The patient has engaged in self-harm behaviors in the form of superficial cutting, and has a history of attempting suicide. Records do not indicate active suicidal ideation. Risk is therefore estimated to be significant.In terms of functional status, the records support a score of 3. The patient has moderate functional impairment as evidenced by troubled relationship with family, defensiveness and argumentativeness with treatment staff, and intermittently troubled relationships with peers.With regard to co-occurrence of developmental, medical, substance use and psychiatric conditions, the records support a score of 1. This dimension assesses the co-existence of disorders across four domains (psychiatric, substance use, medical or developmental) that may complicate the course of treatment. There is no co-occurrence noted in the records.In terms of level of stress of the recovery environment, the records support a score of 3. The patients recovery environment is moderately stressful, as there is conflict between the patient and parents, conflict between parents, the disclosure of past sexual abuse has led to police interviewing parents, and the patient is distressed by parents alcohol use.With regard to level of support of the recovery environment, the records support a score of 2. The patients recovery environment appears to be supportive, as evidenced by parental participation in treatment and parental desire to have a better relationship with their daughter.In terms of resiliency and response to services, the records support a score of 4. The patient has shown poor response to treatment and recovery management. Previous treatment has included inpatient psychiatric hospitalization, multiple residential treatment stays, a partial hospital program, online trauma group therapy, and psychotropic medications The patients symptomatology has persisted despite multiple treatment attempts at various levels of care.With regard to engagement, the records support a score of 3. Although the patient has been attending groups and activities and participating in therapy, records note that the patient avoids vulnerability and authenticity. Records indicate that the patient avoids accepting responsibility for issues and that the patient struggles to trust others and utilize coping skills. Records note that the patient is wedded to [the patient's] victim stance. Notes indicate that the patient can be disparaging of treatment staff and that the patient avoids therapeutic tasks by focusing on what is not receiving from others.These findings give the patient a composite score of 19, which is consistent with Level 3 High Intensity Community Based Services. This level of care generally is appropriate for children and adolescents who need more intensive outpatient treatment and who are living either with their families or in alternative families or group facilities in the community.The patients scores under the six-pronged CALOCUS-CASII Dimensional Rating System take into account the specific needs of the patient for the purpose of treating their illness and its symptoms. The CALOCUS-CASII framework for determining the appropriate level of care for children and adolescents needing mental health treatment is consistent with generally accepted standards of mental health, and it provides determinations that are clinically appropriate in terms of type, frequency, extent, site, and duration. The CALOCUS-CASII dimensions are also free from consideration of the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the requested Intensive Outpatient Program (IOP) services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). Therefore, the Health Plans denial should be overturned.