Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient treatment from 7/15/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The documentation indicates that the patient had been in outpatient psychotherapy prior to her admission to the hospital due to her suicidal ideation for approximately six weeks. The patient had no other notable services as an outpatient.  She has been in the IOP program for over two months prior to the Health Plans denial. The psychiatric admission evaluation indicates the patient was cooperative and was not suffering from suicidal or homicidal ideation.  Her thoughts were logical, and she did not appear to have any cognitive issues that would have prevented participation in outpatient behavioral health therapy. The progress notes do not reflect active suicidal ideation on the part of the patient. The patients parent had concerns that the patient had suicidal ideation. In cases such as this patient, an evidence based instrument such as the CALOCUS is vital in determining necessary level of care for minors, to insure their level of care meets their individual needs at the least restrictive setting possible.  Based on the CALOCUS criteria. The patients risk of harm is rated with a score of 1. This is due to the patients lack of current self harm ideation. Her functional status is also rated as minimal which correlates to a score of 1. The patient has had some deterioration and expected level of functioning in relationships with family. Her co-morbidity is scored a 1. The records do not support that this patient has an active serious medical problem or substance use issues. The patients recovery environment and level of stress is a 2, mild. The patient has issues with family relationships, but they provide a stable housing situation. Her recovery environment level of support is scored a 1, highly supportive. The patients family is actively involved in treatment and attends family therapy sessions on a regular basis. The patients resiliency and treatment history is scored a 3, equivocal. This is due to minimal recent treatment and an unclear success with past treatment. In the category of acceptance and engagement, child/adolescent, the patients score is a 2, constructive. The patient participates actively in therapy. In the area of acceptance and engagement, the patients score is a 2, constructive. The record indicates that the parents work actively and constructively with clinicians. Therefore, according to the CALOCUS criteria, the patients overall composite score is 13. A score of 13 correlates with a treatment intensity level of two, which correlates with outpatient services and not intensive outpatient treatment.  This score is judged by the acuity of the patients symptoms and environment during the period under dispute. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry who recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. The medical literature supports outpatient treatment as well as family therapy in managing suicidal ideation and behaviors for adolescents as cited in the following reference, The study provides preliminary evidence for the use of family-focused treatments for adolescent suicidal behavior in outpatient settings (Pineda and Dadds).  Current literature indicates that effective self harm reduction can occur with therapy available on an outpatient basis such as dialectical behavioral therapy, as indicated in the following reference: A stronger long-term reduction in self harm and a more rapid recovery in suicidal ideation, depression, and borderline symptoms suggest that DBT-A [dialectical behavior therapy] may be a favorable treatment alternative for adolescents with repetitive self-harming behavior (Mehlum, et al).  The guidelines and current evidence based literature indicate that this patient could have been treated with less restrictive therapeutic services. Therefore, intensive outpatient treatment from 7/15/17 forward were not and are not medically necessary for the treatment of this patient.