Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for all or any of the intensive outpatient program (IOP) services at Ignite Teen Treatment LLC. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, 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) co-occurrence of developmental, medical, substance use and psychiatric conditions; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, this patient met the criteria for IOP services.   With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to a history of aggressive behaviors and anger dyscontrol, suggesting poor impulse control. The records did not note attempted suicide or self-harm behaviors. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patients continued difficulty in managing anger, ongoing problems in his relationships with parents, and difficulty maintaining appropriate behavior in treatment despite numerous supports. The records noted that the patient self-isolated in the home.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of psychiatric diagnoses and severe substance use disorder.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to a recent move, the birth of a sibling which has resulted in decreased parental availability, and ongoing difficulties in his relationship with parents. With regard to level of support of the recovery environment, the records support a score of 2 due to the recent birth of a sibling and what appears to be limitations in the parents ability to modulate their affect and utilize more positive parenting strategies when the addressing patients challenging behaviors.  In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment due to limited ability to follow through with treatment recommendations. The records noted prior treatment attempts including outpatient treatment, PHP, and RTC. With regard to treatment acceptance and engagement, the records support a score of 4. The patient attended most groups and activities during the period under review but struggled at times with appropriate engagement, had difficulty being respectful to staff, and was not accepting age-appropriate responsibility for his role in his problems. Thus, the patient has a total score of 21. In this case, the recommended level of care is high intensity community-based services. This is consistent with the level of care that the patient received at the IOP. In this patients case, IOP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, 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, IOP services provided at Ignite Teen Treatment LLC, were medically necessary for the 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 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.