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, the 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 suicidal ideation for which he was hospitalized for six days. The providers have described the patient as impulsive. The patient has a history of eloping. The patient is not endorsing suicidal ideation and there is no indication that there is a history of self-harm. The records support indication or report of incidents of acting without thinking. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) as evidenced by his conflictual relationship with his parents and treatment staff. The patient is noted to be frequently argumentative and defiant. He struggles to complete school assignments and his grades have declined as a result. The patient has conflicted, withdrawn, or otherwise troubled relationships with peers, adults, and/or family, but without episodes of aggression. For dimension 3, the patient has significant co-occurrence (score 3) since in addition to his mental health diagnoses, he has been diagnosed with moderate tobacco use disorder and cannabis use. Substance abuse is present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The provider noted that the patients parental style of discipline is authoritarian, and the patient does not have a good relationship with his stepfather. The patient and his mother struggle to trust one another. There is report of disruption of family and social milieu. For dimension 4B, the patients recovery environment is supportive (score 2). Per the provider, although the patients mother has regularly participated in his treatment and has made changes, his stepfather, who also lives in the home, has not participated, suggesting that there are limitations to the support in the environment. The continuity of family or primary caretakers is only occasionally disrupted, and/or relationships with family or primary caretakers is only occasionally inconsistent. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to services (score 3). The records note that the patient was previously hospitalized on an inpatient psychiatric unit and more recent treatment has included several months in an IOP with slow progress. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has shown limited engaged in treatment (score 3) since the patient often minimizes his symptoms and engages in therapy with interfering behaviors such as eye-rolling and sighing. The patient is described as defiant, negative, and not participating. He has a pattern of not taking accountability and placing blame on others. He struggles to express his emotions and often responds defensively. He has been hostile to staff and disrespectful of rules while in treatment. Overall, the records support that the patient minimizes or rationalizes distressing behaviors and consequences. These findings give the patient a CALOCUS composite score of 20, which is consistent with Level 4 medically monitored community-based services. Moreover, the IOP services are in accordance with the generally accepted standards of mental health and substance use disorder care, and clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the 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.