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 all or any of the 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. With regard to risk of harm, the records support a score of 2. The patient has a low risk of harm due to a history of suicidal ideation but without reports of recent suicidal ideation or self-harm.In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to some challenges in family dynamics, which appear to be improving, and progress in self-care and motivation. With regard to comorbidity, the records support a score of 1. The patient has no comorbidity. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a moderately stressful environment due to conflictual relationships between the parents and between the parents and patient. The records noted that the patient could overthink and catastrophize, tending to isolate. Verbal tensions are apparent. With regard to level of support of the recovery environment, the records support a score of 3 due to her parents efforts to support the patient being challenged by their ongoing tendencies of dismissiveness.In terms of resiliency and treatment history, the records support a score of 2. The patient has significant resiliency and/or response to treatment as she appears to be responding to and incorporating skills she is learning from the IOP, with greater self-awareness and ability to utilize healthier communication strategies.With regard to treatment acceptance and engagement, the records support a score of 2. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers, but with some unexcused absences. Thus, the patient has a total score of 15. In this case, the recommended level of care is low-intensity community based services. This is inconsistent with the level of care that the patient has been and is receiving at IOP. In this patients case, IOP level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, IOP services were not and are not medically necessary for the treatment of this patient.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 sub-specialty 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.