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) 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. Applying the CALOCUS framework, the patient meets the criteria for IOP services. The patient has been at low risk of harm (score 1) without any reported suicidal ideation or attempts. The patient has a history of aggression toward her family. The patient has demonstrated mild functional impairment (score 2) due to her ability to hold a job and stay enrolled in high school with online home studies. The provider noted concern for the patients substance use putting her in vulnerable situations. The patient has minor comorbidities (score 2) as she was diagnosed with major depressive disorder in addition to cannabis and anxiolytic/sedative hypnotic dependence. The patients recovery environment is moderately stressful (score 3) considering her significant for ongoing conflicts with her mother. The patient indicated that her home is a trigger for her desire to use substances. The patients recovery environment provides limited support (score 3). The records report severe parent-child relational problems resulting in the patient not viewing her parents as allies or as supports. Her parents have a limited ability to respond appropriately to the patients behavioral problems. The patient has shown poor response to treatment (score 4) as she reportedly relapsed on Xanax and alcohol, then required physical restraint due to aggress behavior on 5/5/20. The patient has been incompletely engaged in treatment (score 3) as she appears to participate and accept help, but she still demonstrates urges to use. She has acknowledged that her relationship with mother is a major trigger. These findings give the patient a composite score of 18, which is consistent with high intensity community based services, such as IOP. Based on the CALOCUS, this patient meets the requirements for medically necessary IOP services. Therefore, the IOP services were 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.