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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient program (IOP) services. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted national standard for determining the appropriate level of care for children and adolescents. The patient met the following criteria: The patients risk of harm is scored a 2, which correlates to some risk of harm. The records did not appear to indicate that this patient has a history of suicide attempts. The patient did not have any suicidal ideation. However, the patient does continue to have episodes of impulsivity. The patients functional status is scored a 2, which correlates to mild functional impairment. The documentation indicated that the patient was performing adequately in school. The patient was maintaining hygiene. The patient was improving in the patients ability to control the patients anger. The patients co-morbidity is scored a 2, which correlates to minor co-morbidity. The records did not mention a major psychiatric diagnosis on the chart. The patients treatment revolved around the patient impulsivity and anger problems with the patients parents.As for the patients recovery environment, the patients environmental stress is scored a 3, moderately stressful environment. The patient reported that there is a lot of yelling and contention in the home. However, the record noted that the patient has been able to make improvements as to how the patient responds to the acrimony in the home. With regard to the environmental support, the patient is scored a 2, which correlates to a supportive environment. The patients parents are supportive of the patient. The patients resiliency is scored a 2, significant response to treatment. The patient has made improvements since he started the IOP. The patients provider stated that the patients mood was stable and that he was getting along with his parents. The patient was sleeping well and had no anxiety or depression. The patients provider stated that he was compliant with his medications, he was eating well, and that he had minimal irritability. The patient did not have any suicidal or homicidal ideation. The patient was using his skills that he learned in his everyday life to cope with stressors. The patients acceptance and engagement is scored a 2, constructive. The patient is cooperative and he is friendly with staff. The patient is accepting of treatment recommendations. According to the CALOCUS criteria, this patients total composite score is 15. The patient continued to need treatment to address the patients aggressiveness and impulsivity, but his treatment could have been performed in a less restrictive environment. The patient would have met criteria for a routine outpatient psychiatric care. Therefore, IOP services were not medically necessary. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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.