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

The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) behavioral health 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) medical, addictive 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 CALOCUS, the patient is at some risk of harm (score 2) due to a history of suicidal thoughts and lack of current suicidal thoughts. The patient expressed self-harm thoughts but no suicidal ideation. The progress notes indicate that the patient and initially presented due to self-harm thoughts and mood symptoms. The patient has not been aggressive with anyone in the program and has not exhibited emotional or physical outbursts during the IOP sessions. The patient has demonstrated mild functional impairment (score 2) with significant improvement in function following a period of deterioration as referenced by intact sleep, eating, and hygiene patterns as well as appropriate interactions with peers. The patient has no documented comorbid conditions (score 1). The records do not indicate that the patient has any active medical problems or substance use issues affecting treatment. The patient exhibits intermittent hallucinations that last a few seconds and occur up to twice per week. These hallucinations did not appear to affect the patient in a significant manner. It appears that the patients mood has been stable throughout therapy sessions. The patients recovery environment is mildly stressful (score 2) since the patient requires adjustment with attending a new school. The patients recovery environment is highly supportive (score 1) as the patients family is actively involved with treatment. The patient has shown significant resiliency and response to treatment (score 2) with substantial improvement in behaviors and recent demonstration of ability to deal with stress due to therapy skills learned in the IOP. In addition, the patients mood and hallucinations symptoms have also improved significantly during the IOP sessions. The progress notes indicate the patient has made steady progress throughout the IOP. The patient has learned significant coping skills and has been able to apply them. The patient recently underwent a stressful breakup with a significant other and was able to use coping skills to prevent any self-harm or active suicidal ideation from occurring. The patient has been constructive in treatment (score 2) as the records document that the patient participates in therapy, appears to be motivated for treatment, and has strong relationships with the providers. The progress notes indicate that the patient has been cooperative in treatment and engaged with the providers. The patients parents have been constructive with the patients treatment (score 2) as they have worked actively and constructively with providers. This gives the patients presentation a composite score of 14, which correlates with outpatient services. Therefore, the IOP behavioral health services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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 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.