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 Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment.With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm. The records noted that the patient carried a knife on his person for protection, threatened peers at school, and made a bomb threat. The records noted that the patient became agitated with a peer during an IOP session and punched the peer in the face. The records noted that the patient was easily angered, had periods of inability to care for himself, and had a history of suicidal ideation and of self-harm by poking himself with a knife. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to reported struggles with maintaining hygiene, a lack of ambition to complete tasks and engage in pleasurable activities, lack of motivation, and an inconsistent ability to complete chores. The patient had been expelled from school due to behavioral issues. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of ADHD, learning disorders, and depressive disorder. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a mildly stressful environment due his father recently relapsing on substances, his mother being out of town for extended periods of time and physically and emotionally unavailable, and an older sister with mental health issues. The patient had a family history of losing a  grandfather to suicide. The records noted that the patient was socially isolated. With regard to level of support of the recovery environment, the records support a score of 4 due to his fathers relapse on substances, his mothers absence for considerable periods, and his older sisters mental health struggles. The records noted that the patient had few, if any, friends, and outpatient teletherapy or virtual psychotherapy due to the COVID-19 pandemic severely limited in-person contact and support. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment. Previous outpatient treatment had not achieved complete remission of symptoms nor optimal control of symptoms despite several years of individual psychotherapy. While in IOP, the patient exhibited incremental responses to treatment and the improvements observed occurred in a highly structured and highly supportive environments. With regard to treatment acceptance and engagement, the records support a score of 3. The patient engaged in treatment but then struggled to identify alternate means of coping with peers behaviors towards him other than aggression and struggled with consolidating and consistently utilizing coping skills learned during treatment. Thus, the patient has a total score of 22. In this case the recommended level of care is medically monitored community-based services. This is consistent with the level of care that the patient received at the IOP. In this patients case, IOP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, IOP services were medically necessary for the 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 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.