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 (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, this patient meets the criteria for IOP services.With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to a history of suicidal ideation and a suicide attempt by overdose, superficial cutting, and distress surrounding recent disclosures of abuse.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient has been purging daily. 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 5. The patient has an extremely stressful environment due to recently disclosing a history of abuse. The records note open investigations into the allegations of abuse, and that the patient has had to undergo interviewing as a result. The patient has a distant relationship with her father and a strained relationship with her mother. With regard to level of support of the recovery environment, the records support a score of 2 as the patients parents are participating in treatment and are cooperative with ongoing investigations regarding allegations of abuse. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment as her treatment history has included outpatient psychotherapy, psychiatric care including with psychotropic medications, a brief psychiatric hospitalization, and IOP. With regard to treatment acceptance and engagement, the records support a score of 2. The patient demonstrated adequate engagement.Thus, the patient has a total score of 19. In this case, the recommended level of care is high intensity community-based services. This is consistent with IOP level of care. In this patients case, IOP level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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. Therefore, IOP services were and are medically necessary for the 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 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.