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

Findings:  The physician reviewer found that 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 the 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 has been hospitalized. The patient does not have a history of attempting suicide or engaging in self-harm behaviors. The patient also has a history of expressing suicidal ideation while under the influence of alcohol. The records document binge or excessive use of alcohol and other drugs resulting in potentially harmful behaviors. For dimension 2, the patient has demonstrated mild functional impairment (score 2) given the ability to work and enroll in summer school while attending and participating in IOP. The patient has experienced some difficulties in the relationship with both brother and parents but is working toward improving those relationships. The records describe several times in the recent past in which patient successfully navigated anxiety provoking situations. The patient has shown some evidence of minor failures of function in any of several areas of living; school, family, peers. These periodic or momentary failures are time limited. For dimension 3, the patient has significant co-occurrence (score 3) considering the diagnosis of attention-deficit/hyperactivity disorder (ADHD), which is a neurodevelopmental disorder. The patient also has a history of abusing substances. The patient is currently engaged in a substance use recovery support group. There is documentation of developmental disability present that may adversely affect the presenting condition, and/or may require significant augmentation or alteration of treatment for the presenting condition or co-morbid condition, or adversely affects the presenting condition. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The provider noted that the patients father has a history of depression and difficulty managing anger. The patients older brother has struggled with suicidal ideation. There is conflict between extended family members, and this is stressful for the patient. The records document disruption of family and social milieu. For dimension 4B, the patients recovery environment has been supportive (score 2). The provider indicated that the patients parents have been supportive as evidenced by their participation in family therapy and other parts of the patients treatment. The patient has talked about feeling safer emotionally with the father. The patient has successfully reached out to the mother for support. The patients family are willing and able to participate in treatment of requested to do so and have capacity to effect needed changes. For dimension 5, the patient has shown moderate or equivocal resiliency and response to services (score 3). Prior treatment has included brief outpatient therapy, IOP, and at least one inpatient psychiatric hospitalization. Thus, previous experience treatment in at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has demonstrated adequate participation in services (score 2). The records indicate that patient has participated in group, individual, and family therapies. The patient has been 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 Level 3 high intensity community-based services. Moreover, the IOP services were and are in accordance with the generally accepted standards of mental health and substance use disorder care, 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 the 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.