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

The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The 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.For dimension 1, the patient has been at low risk of harm (score 1) given the mention of possible self-harm once in the records but no report of suicidal ideation or aggression. There is no indication of current suicidal or homicidal thoughts or impulses, with no significant distress, and no history of suicidal or homicidal ideation. For dimension 2, the patient has demonstrated mild functional impairment (score 2) considering his legal issues related to his substance use. He is attending the IOP program, was in school, and interacts with others, but not well. This supports some evidence of minor failures of function in any of several areas of living such as school, family, and peers. For dimension 3, the patient has minor comorbidities (score 2) since there are no medical or developmental issues reported in the records. He has three mental health disorders and one substance use disorder. Transient, occasional, stress-related psychiatric symptoms are present that has no discernable impact on the presenting condition. For dimension 4A, the patients recovery environment is moderately stressful (score 3) given his conflicts with his parents and sister. The patients parents are co-parenting and struggling to be consistent with the patients needs. There is disruption of family and social milieu. For dimension 4B, the patients recovery environment is supportive (score 2) due to his parents participating in therapy, family meetings, and seeking other treatments. The patients family are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited poor resiliency and response to treatment (score 4). The records indicate that he has not substantially improved with treatment. Attempts to maintain whatever gains that have been attained in intensive treatment have limited success, even for limited time periods or in structured settings. For dimension 6, the patient has been incompletely engaged in treatment (score 3) since he has been resistant to participating in group, but he is coming to therapy. The patient is not invested in treatment including homework assignments. These findings give the patient a composite score of 17, which is consistent with high-intensity community-based services. For these reasons, the psychiatric IOP services provided were and are medically necessary for treatment of this patient.