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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, the patient meets the criteria for IOP services. For dimension 1, the patient has been at some risk of harm (score 2) due to reports of intense cravings for substances with a recent relapse. The patient has a history of suicidal ideation, self-harm behaviors, and overdoses. The patient has a history of stealing medications and he has engaged in other impulsive behaviors. The patient has denied suicidal ideation since the first date of denial. The records document indication or report of occasional impulsivity with minimal consequences for self or others. For dimension 2, the patient has demonstrated mild functional impairment (score 2) given his ability to remain abstinent from substances with the exception of one recent relapse. The patient is attending IOP and participating in his treatment, although he continues to have conflict with his father. There is some evidence of minor failures of function in any of several areas of living: school, family, peers. These periodic or momentary failures are time limited. For dimension 3, the patient has significant co-occurrence (score 3) considering his history of obsessive compulsive disorder and cannabis use disorder. The patient also struggles with insomnia. The patient has been experiencing intense cravings for drugs. The patients recent substance use that has significant impact on the presenting condition has been arrested due to use of a highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The patient endorses multiple stressors including cravings for substances, tension in his relationship with his father, and conflict with his girlfriend. The provider noted that the patients family has difficulty communicating without conflict. The patients parents are divorced and struggle to communicate and find ways to compromise. The records support disruption of family milieu. For dimension 4B, the patients recovery environment provides limited support (score 3) given his fathers struggles to regulate his emotions. The provider noted that the patients father threatened to punch the patient during a family therapy session. The patients family or primary caretakers demonstrate only partial ability to make necessary changes during treatment. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to services (score 3). The records indicate that prior treatment has included outpatient therapy, multiple psychiatric hospitalizations, and residential treatment. The provider noted that there has been a lack of progress in family sessions and the patients progress in IOP has been slow. There is report that previous experience in treatment at low level intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patients engagement in services has been limited (score 3). The records indicate that although the patient is engaged in treatment in that he participates in group, individual, and family therapy, he continues to glamorize substance use. The patient minimizes or rationalizes distressing behaviors and consequences. These findings give the patient a composite score of 19, which is consistent with Level 3 high intensity community-based services. Moreover, the IOP services were and are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the IOP services were and are medically necessary for treatment of this patient.  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 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.