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

Nature of Statutory Criteria/Case Summary: The patient has a history of attention-deficit/hyperactivity disorder (ADHD), parent-child relational problem, and unspecified anxiety disorder. He was admitted to intensive outpatient program (IOP) services. Records note that the patient had a resistant and irritable attitude. His insight was poor and although his group participation was minimal, he was willing to participate. He was noted to spontaneously ask peers for help with impulsive behavior. The provider noted that he had an attentive, neutral mood with moderate participation, and a cooperative attitude.The Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool to support accurate level of care recommendations. Applying CALOCUS, a portion of IOP services that were provided were medically necessary, while the other portion of IOP services were not and are not medically necessary for treatment of this patients behavioral health issues. In terms of risk of harm, the records support a score of 1 due to lack of documentation of ideation of self-harm on or self-harming behaviors. Regarding functional status, the records support a score of 2. He was displaying response to treatment and willing to talk about his feelings. He had minor comorbidities for a score of 2 based on the diagnoses of ADHD and anxiety disorder. Regarding his recovery environment level of stress, the records support a score of 2, as his treatment environment is mildly stressful. His recovery environment level of support is also supportive, for a score of 2. Pertaining to resiliency and treatment history, the records support a score of 2 given limited but increased response to treatment. He spontaneously asked peers to help with impulsive behavior. Regarding the acceptance and engagement of the patient, the records support a score of 2, as the patient has been constructive. He was reportedly able to take more responsibility for his actions, but the records indicate he was not participating in the groups. His parent has been engaged in treatment for a score of 2. This gives the patient a composite score of 15, which is consistent with outpatient services. The records indicate that the patient met criteria for a portion of the IOP level of care. However, the other portion of IOP services were not medically necessary.Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Specifically, our medical expert decided that a portion of IOP services was medically necessary for the patient, and the other portion was not medically necessary for the patient.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.