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

Nature of Statutory Criteria/Case Summary: Applying the evidence based American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) framework for determining the appropriate level of care for adolescents needing mental health treatment, this patient meets the criteria for continued IOP services. 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. CALOCUS, to insure the level of care meets the individual patients needs at the least restrictive setting possible. This patient presents with some risk of harm (score 2) due to the patients history of recent impulsive behaviors. The progress notes indicate the patient has made some minimal improvements behaviorally while in treatment for the past two months. The patient has demonstrated mild functional impairment (score 2) with deterioration in his expected level of functioning in relationships with peers, adults and family, he is struggling with daily behavioral issues. Further, the patient presents with moderate comorbidity (score 2) with a diagnosis of diabetes that is an active problem and he does not participate in adequate self-care at times. The patients recovery environment is moderately stressful (score 3) given his problematic issues with family relationships. The patient was noted to continue to have a stressful relationship with his family due to his lack of ability to follow rules. The patients recovery environment is supportive (score 2) as his family actively participates in treatment, however, their relationship is strained. The patient has demonstrated limited response to prior treatment (score 3) with minimal progress in RTC. The patient has been obstructive in treatment (score 3) with minimal participation. In addition, the patient continues to have very impulsive behaviors that included a recent attempt to leave the facility in freezing weather. The patients parents have been constructive (score 2) and have worked actively with the patients providers. This gives the patients presentation a composite score of 19, which correlates with intensive outpatient services, consistent with IOP level of care. Accordingly, the IOP services were and are medically necessary for treatment of this patients behavioral health issues. 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.