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 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) developmental, medical, substance use 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 the CALOCUS framework, this patient met the criteria for IOP services. For dimension 1, the patient was at significant risk of harm (score 3) due to a history of self-harm and suicidal statements. The provider noted that the patient demonstrated an unstable sense of self and perception of limited family support. The patient also has a history of substance use, which contributed toward the risk towards self-harm. No active suicidal ideation, but extreme distress and a history of suicidal behavior existed. For dimension 2, the patient exhibited mild functional impairment (score 2) due to a history of neglect of expected and age appropriate completion of chores, such as cleaning the pet cage and bedroom. The patient showed poor affect regulation. The patient developed minor but consistent difficulties in social role functioning and meeting obligations such as performing at expected level in work or school but maintaining ability to continue in those roles. For dimension 3, the patient has significant comorbidities (score 3) given the history of anxiety and providers concern for an eating disorder and parent-child relational problem, as well as gender dysphoria, and an emerging substance use disorder. Ongoing or episodic substance use occurring despite negative consequences with significant or potentially significant negative impact on the course of any co-occurring psychiatric disorder. For dimension 4A, the patients recovery environment is highly stressful (score 4). The records document conflict with both parents, and siblings with a history of substance abuse. Serious disruption of family or social milieu which may be due to illness, death, divorce or separation of parent and child, severe conflict, torments and/or physical or sexual abuse. For dimension 4B, the patients recovery environment provided limited support (score 3) given the highly stressful conflict with both parents. The patients siblings have a history of substance abuse and legal difficulties. Very few actual or potential sources of support were available to the patient. For dimension 5, the patient has demonstrated poor resiliency and response to treatment (score 4). The patient has a history of poor response to outpatient level of care and was able to show limited progress in IOP. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient was incompletely engaged in recovery (score 3) with difficulties expressing concerns about anxiety and depression in groups. This supports an ambivalent, avoidant, or distrustful relationship with clinicians and other care providers. These findings give the patient a composite score of 22, which is consistent with medically monitored community-based services. For these reasons, the IOP services were medically necessary for 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 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.