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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for mental health intensive outpatient program services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in order to objectively determine the appropriate level of care for the patient, the Child and Adolescent Level of Care Utilization System (CALOCUS) was utilized in this review. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. This patient met the following criteria:The patients risk of harm is scored. There is no documentation stating that the patient had a suicide attempt or had a suicidal ideation. The patients functional status is scored, which correlates to moderate functional impairment. The patient continues to have conflicted relationships with his family and peers. The record noted that the patient may have some legal issues relating to a threat the patient made towards a peer. The patients co-morbidity is scored, significant co-morbidity. The patient has a co-morbidity of major depressive disorder, generalized anxiety disorder, ADHD, cannabis use disorder, and alcohol use disorder. The records did not report that this patient had any major medical problems. With regards to the patients recovery environment, his environmental stress is scored which correlates to moderately stressful environment. The patient has expectations for performance in school and at home that creates discomfort. The patient will at times have conflicts with the patients parents. The record reported a history of physical altercations with his father. The patients environmental support is scored, which correlates to supportive environment. The patients mother is supportive of the patient. The patients resiliency is scored, which correlates to equivocal response to treatment. The patient has made modest improvements in his substance use. The patient has maintained recovery for moderate periods of time, but only with strong professional support in structured settings. With regards to acceptance and engagement, his score, obstructive. This patient is resistant to group activities and reportedly mocks the process. The patient will not commit to working a program and obtaining a sponsor. The patient asked a peer for marijuana. The record has noted that the patient continues to lie to the patients parents unless confronted. The patient is able to be redirected and will apologize when confronted. According to the CALOCUS criteria, this patient has a composite score. Based on this criteria, this patient continues to meet criteria for IOP. The patient has made modest improvements in his ability to initiate self-soothing strategies to help with his anxiety. However, due to the patients lack of motivation for sobriety and acceptance for treatment, it is likely that if the patient is stepped down to routine outpatient treatment that the patient would relapse and again require more intensive treatment. For these reasons, mental health IOP services were and are medically necessary for the treatment of this patients medical condition. 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. 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.