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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for intensive outpatient program (IOP) level of care services. Findings:  The physician reviewer found that 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 met the criteria for IOP services. For dimension 1, the patient was at significant risk of harm (score 3) due to recurrent suicidal ideation with plan, cannabis abuse and driving under the influence, and problems completing hygiene and self-care. Significant current suicidal ideation with some intent and plan, with an ability for the adolescent and his family to contract for safety and carry out a safety plan. The patient expressed some reason not to carry out such behavior. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given his problems with self-care. The provider noted that the patient showed gradual improvement in insight and mood while attending IOP and participating in groups over the course of his treatment. Recent gains and stabilization in functioning were achieved while participating in a structured, protected, and enriched service. For dimension 3, the patient has significant co-morbidities (score 3) considering his continued regular cannabis use. Substance abuse was present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment was mildly stressful (score 2) due to his difficulties adjusting to online school and social isolation related to the pandemic. Significant transition requiring adjustment, such as change in household members, or new school or teacher. For dimension 4B, the patients recovery environment was supportive (score 2). The provider noted that the patients parents were active participants in treatment. Family caretakers were willing and able to participate in treatment of requested to do so and had capacity to effect needed changes. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to treatment (score 3) as demonstrated by his recent decline in mood and functioning and his struggles to adjust to the changes brought on by the pandemic. The patient demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development. For dimension 6, the patient was constructive in treatment (score 2). The provider noted that the patient was an active participant for most of his IOP admission. The patient showed some reluctance to cease substance use while in IOP. The patient was able to develop a trusting, positive relationship with clinicians and other care providers. These findings give the patient a composite score of 18, 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, patients symptoms can be characterized as slowly evolving, given the chronic and recurrent nature of his depression and suicidal ideation, and the gradual progress the patient made in IOP treatment. For these reasons, the IOP level of care was medically necessary for 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 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.