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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for Mental Health Intensive Outpatient Program (IOP) Services provided 3 times per week.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 children needing mental health treatment. In this case, in terms of risk of harm, the records support a score of 2, which corresponds with some risk of harm. This is due to reference to past suicidality in the patients records, with no suicidal ideation reported in IOP notes. With regards to functional status, the records support a score of 3, which reflects moderate functional impairment, due to conflict with parents, an unhealthy relationship, and some difficulties in school. In terms of comorbidity, the records support a score of 2. The patient had minor co-morbidity, due to anxiety, dysthymia, ADHD, and a history of cannabis use. With regards to the level of stress of the recovery environment, the records support a score of 2. The patients recovery environment is mildly stressful due to conflict with parents and some school struggles. In terms of the level of support of the recovery environment, the records support a score of 2, which corresponds with a supportive environment, due to the fact that the patients parents participated in treatment. With regards to resiliency and treatment history, the records support a score of 2, which reflects significant resiliency and/or response to treatment. This is due to the patient's ability to abstain from substances while in treatment, and her ability to attend treatment regularly and follow the rules of the program. In terms of acceptance and engagement of the patient, the records support a score of 2. The patients score reflects that the patient was constructively engaged, due to her participation in and cooperation with treatment. Thus, the patient has a composite score of 15. This composite score corresponds with Level 2: Low-Intensity Community-Based Services. CALOCUS level of care definitions state that children and adolescents appropriate for Level Two services generally do not require the extensive systems coordination and case management of the higher levels of care. Level Two treatment intensity ranges from one hour every four weeks, up to two hours per week. After two months of IOP, the patient was no longer exhibiting the behaviors or symptoms that would justify continued intensive treatment. The patient no longer needed the IOP level of care, and could have been transferred to lower-level outpatient services. Accordingly, Mental Health Intensive Outpatient Program Services provided 3 times per week were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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.