Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for three (3) hours per week of in-person individual therapy for a minimum of three (3) months. 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. With regard to risk of harm, the records support a score of 3 due to a history of poor frustration tolerance, inability to control anger, physical aggression towards others, passive suicidal ideation and self-harm.  In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to recent gains while in treatment. The patient had a history of difficulty completing schoolwork and outbursts of anger at school. With regard to comorbidity, the records support a score of 1. The patient did not have comorbidities. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a moderately stressful environment due to a strained relationship with his mother at home, and due to struggles with school, which triggered his outbursts of anger. With regard to level of support of the recovery environment, the records support a score of 3 due to his mothers report of difficulty accessing treatment to meet the patients emotional and behavioral needs. In terms of resiliency and treatment history, the records support a score of 3. While the patients symptoms improved while receiving intensive outpatient program (IOP) services, the patients behavior has regressed, suggesting difficulty maintaining recovery in the absence of strong professional support.With regard to treatment acceptance and engagement, the records support a score of 2. The patient actively engaged in treatment. Thus, the patient has a total score of 19. In this case, the recommended level of care is high intensity community-based services. In this patients case, three (3) hours per week of in-person individual therapy for a minimum of three (3) months are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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, three (3) hours per week of in-person individual therapy for a minimum of three (3) months are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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.