Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for 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 met the criteria for RTC servicesWith regard to risk of harm, the records support a score of 2. The patient had some risk of harm, due to a history of suicidal ideation without a history of self-harm or suicide attempts. In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment as the patient struggled academically due to a learning disorder and maintained average grades. She struggled in her relationship with her parents due to her irritability. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of a neurodevelopmental disorder, attention deficit hyperactivity disorder (ADHD), and a reported auditory processing learning disorder. ADHD can cause mood dysregulation and is a risk factor for depression. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to her grandfather, who has dementia, living with the family and struggles in school due to her learning disorder. With regard to level of support of the recovery environment, the records support a score of 2 as the patients parents appear supportive. She has a learning specialist at school and services/support for her learning disorder. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment as prior treatment has included outpatient psychiatric care and outpatient therapy.  With regard to treatment acceptance and engagement, the records support a score of 3. The patients parents were not engaged in treatment in the first several months, but their participation improved over time. Thus, the patient has a total score of 18. In this case, the recommended level of care is high intensity community-based services. This is consistent with the level of care that the patient received at the IOP. In this patients case, IOP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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 medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.