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

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee requested reimbursement for all or any of the intensive outpatient program (IOP) services provided from September of 2020 to February of 2021 at Insight Treatment Program.There are two issues for this case. First, at issue is whether all or any of the intensive outpatient program (IOP) services provided from September of 2020 to the end of 2020 at Insight Treatment Program were medically necessary to treat the enrollees condition. Second, at issue is whether all or any of the IOP services provided from beginning of January 2021 to February of 2021 at Insight Treatment Program were medically necessary to treat the enrollees medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.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. 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.With regard to risk of harm, the records support a score of 3. The patient had significant risk of harm due to previous suicide attempts, continued self-harm during intensive outpatient treatment, and impulsivity, including taking five sleeping pills to get high in January 2021.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflicted relationships with her parents and academic struggles.With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity due to occasional substance use, such as taking sleeping pills to get high.In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to the disruptions of the pandemic, recent break-up with her boyfriend, and death of her middle school teacher, as well as academic pressures.With regard to level of support of the recovery environment, the records support a score of 2 due to her parents active participation in treatment and treatment planning.In terms of resiliency and treatment history, the records support a score of 4. The records noted poor resiliency and/or response to treatment. The patient continued to struggle with emotional dysregulation, impulsivity, and self-harm after an inpatient hospitalization, several medication trials, and extended time in IOP.With regard to treatment acceptance and engagement, the records support a score of 3. The patient participated in treatment but minimized the seriousness of self-harm and substance use in January 2021.Thus, the patient has a total score of 19. The patient qualifies for Level Three: High Intensity Community-Based Services. In this case, the patient had recurrent depression. In October 2020, two months after she enrolled in the IOP, she was overwhelmed, struggling in school, and starting to shutdown. The patients IOP provider recommended that her parents consider a higher residential level of care. Two months later, in December 2020, the patient was still self-harming. As late as January 2021, she impulsively took sleeping pills to get high. The clinical record demonstrates that the patient continued to meet criteria for IOP treatment throughout the period under review. Additionally, in this patients case, IOP services provided from beginning of January 2021 to February of 2021 at Insight Treatment Program were in accordance with the generally accepted standards of mental health and substance use disorder care. 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, intensive outpatient program (IOP) services provided from September of 2020 to February of 2021 at Insight Treatment Program were medically necessary for treatment of the patients medical condition.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 sub-specialty 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.