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

Nature of Statutory Criteria/Case Summary: The enrollee has requested intensive outpatient psychiatric level of care. The Health Plan has denied this request indicating that the requested services were not and are not medically necessary for treatment of the enrollees behavioral health condition.The Child and Adolescent Level of Care Utilization System (CALOCUS) 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, moderate risk of harm. The patient has a history of a suicide attempt by overdose. The patient has chronic suicidal ideation and thoughts of self harm. The patient continued to have suicidal ideation but had no intent or plan. She continued to have thoughts of self harm and acted out on her self harming impulses. The patients functional status is scored, moderate functional impairment. The documentation states that the patient was thinking of getting part time work. The patient did not wish to return to school. The patient had conflicted relationships with her family. The family reported they have to walk on eggshells around the patient to avoid upsetting her. The patients parents reported that they are seeking to place the patient into a residential treatment center. The patients co-morbidity, significant co-morbidity. The patient has co-morbidities of major depressive disorder, anorexia nervosa, and anxiety. The patient weighed pounds at a height of. She was in the percentile for weight. The patients environmental stress is scored, mildly stressful environment. The patient has mild interpersonal conflicts with her family at home. Her environmental support is scored, supportive environment. The patients parents are participating in family therapy. The patients parents are supportive of the patient.  The patients resiliency is scored, equivocal response to treatment.  Prior treatments have helped the patient restore her normal body weight. However, the patient continues to have suicidal ideation and impulses to self harm. Recovery has been maintained for moderate periods of time but only with strong professional support. The patients parents state that the patient had not improved in her functionality. The patients provider noted that the patient requires a higher level of care at a residential treatment center. Acceptance and engagement is scored, constructive. The patient was able to develop positive relationships with clinicians and participate in treatment. She actively participates in treatment planning and cooperates with treatment. According to CALOCUS, the patients total composite score is 18. Based on this score, the patient meets criteria for IOP level of care. As such, IOP psychiatric level of care was and is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that 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 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.