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 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. Applying the CALOCUS framework, this patient meets the criteria for IOP services. For dimension 1, the patient has been at significant risk of harm (score 3) due to a history of self-harm and reports of extreme distress. No active suicidal or homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given his interpersonal conflict with parents, struggles to interact with peers, and academic difficulties with attending school. Recent gains and/or stabilization in functioning have been achieved while participating in a structured, protected, and/or enriched service as demonstrated by the patients gradual progress in attending IOP and participating in groups over the course of his treatment. For dimension 3, the patient has no evidence of medical illness, substance abuse, developmental disability, or psychiatric disturbances apart from the presenting condition (score 1). For dimension 4A, the patients recovery environment has been moderately stressful (score 3) considering the patients inability to attend school and his struggles to participate in groups at IOP. The records document that the patients conflict with his parents has contributed to his environmental stress. Role expectations that exceed child or adolescents capacity given age, status, and developmental level. For dimension 4B, the patients recovery environment is supportive (score 2) given his parents active participation in treatment. Family are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited moderate or equivocal resiliency and/or response to treatment (score 3) since previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. This is evidenced by the patients lack of improvement after two years of outpatient individual therapy prior to IOP. For dimension 6, the patient has been constructive in treatment (score 2) due to his participation in treatment, with some inconsistent attendance that improved during treatment. Able to develop a trusting, positive relationship with clinicians and other care providers. This gives the patient a composite score of 17, which is consistent with high intensity community-based services, such as IOP. Per CALOCUS, Minimal oversight should be required for this level of services and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more slowly evolving conditions. In this case, the patients symptoms can be characterized as slowly evolving given the chronic nature of symptoms and the gradual progress while in IOP treatment. Current records demonstrate continued a need for IOP treatment through the time period documented. Therefore, IOP services 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.