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

Nature of Statutory Criteria/Case Summary: An enrollee was diagnosed with depression. She was admitted to an intensive outpatient program (IOP). Psychiatrist progress notes report the patient is depressed but able to use skills when feeling down. She engaged well in a group and was responding to positive feedback. She was sleeping eight to 10 hours a night, and her energy was within normal limits. The patient was noted to be getting along with family with one conflict when she did not use her skills. Her appetite is within normal limits of two meals daily. She reported an ok mood with a congruent affect and denied side effects from medications. Medications are noted by the provider to include Sertraline 75mg every morning and Abilify 5mg at night. Individual therapy notes indicate the patient reported two days of family conflict for the week prior. The patient reported she was unhappy when her father used invalidating statements.  She denied any suicidal or homicidal ideation. She reported feeling more hopeful with improved problem-solving abilities. Therapy progress notes indicate that the patient reported experimenting with cannabis one time the week prior. The patient expressed remorse for using cannabis. The patient reported in progress notes that she had made improvements since starting treatment. She reported her mood had been steady. Her depression was minimal, and she denied anxiety. She was sleeping well through the night. She was medication compliant and reported no side-effects. Her appetite was the same and she was not eating at school. She denied any recent drug use or urges. Her medications were sertraline 75mg each morning, and Abilify 5mg at bedtime.  At issue in this case is whether the IOP services received were medically necessary for treatment of this patient. The records indicate continued mild oppositional behavior at school. Her teachers indicated that she would cooperate in school when rapport was established. The progress notes indicate that the patient used cannabis on at least one occasion. She was noted to have good social skills and interaction with peers at school. Her mood was stable without signs of any significant depression or anxiety. In therapy, the patient discussed her feelings regarding her parents and other stressors. She did not express any suicidal or homicidal ideation or psychosis. There was no indication of serious medical issues or significant behavioral issues at school. She was able to verbalize the importance of some of the feedback she received in therapy. The progress notes did not indicate that the patient was suffering from severe or serious functional impairment or that she presented with serious functional impairment. 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) 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. Scoring on CALOCUS for this patient was one for no risk of harm. The patient did not have self-harm or suicidal ideation. Regarding functional status, her score was one for minimal deterioration, as the patient demonstrated some decrease in expected level of functioning in relationships with family. However, she was functioning well in school and at home. With regard to co-morbidities, the score was two for mild, as the patient did not have active serious medical problems and her substance use was described as mild overall. The patients recovery environment level of stress scored at two for mild. The patient had issues with family relationships, but had a stable housing situation. The recovery environment level of support was a one for highly supportive. The patients family was actively involved in treatment and attended family therapy sessions on a regular basis. Regarding resiliency and treatment history, the score was three for equivocal due to apparent success in the first several weeks of the IOP but unclear success with treatment before the IOP. The patients acceptance and engagement was scored at two for constructive. The patient was participating actively in current therapy. Regarding the parents acceptance and engagement, the records supported a score of two, constructive, as the parents worked actively and constructively with clinicians. This gives the patients presentation a composite score of 14, which correlates with outpatient services. According to the CALOCUS, the patients presentation did not meet criteria for the requested level of care. Therefore, the IOP services received were not medically necessary for this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.