Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for intensive outpatient program (IOP) services. 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) developmental, medical, substance use 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. Applying the CALOCUS framework, this patient met the criteria for IOP services. For dimension 1, the patient was at significant risk of harm (score 3) due to self-harm, substance abuse, and a history of impulsive aggression as evidenced by punching a fellow student prior to admission. The records document that even after months of IOP treatment, the patient remained at significant risk of harm. There was indication or report of incidents of acting without thinking, or physically aggressive actions that endangered self or others. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given his interpersonal conflict with family members and his struggles to attend school regularly, which placed him at risk of transfer to a continuation school. Recent gains and/or stabilization in functioning have been achieved while participating in a structured, protected, and/or enriched service, as demonstrated by the patients sobriety over several months while enrolled in IOP. For dimension 3, the patient has significant co-morbidities (score 3) including substance abuse as well as OCD and ADHD. Substance abuse is present, with significant adverse effect on functioning and the presenting condition. For dimension 4A, the patients recovery environment was mildly stressful (score 2) considering his conflict with family members, perceived lack of emotional support at home, and struggles to maintain academic performance and participation in school. There were expectations for performance at home or school that created discomfort. For dimension 4B, the patients recovery environment was supportive (score 2) due to his mothers participation in treatment and treatment planning. Family was willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient exhibited poor resiliency and response to treatment (score 4). The records document that previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure to treatment. The patient continued to report significant distress and to engage in self-harm, even after residential treatment and weeks of IOP treatment. For dimension 6, the patient was incompletely engaged (score 3), considering his resistance to accepting responsibility for her behavior, and her tendency to blame others. The patient acknowledged existence of a problem but resisted accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. This gives the patient a composite score of 20, which is consistent with medically monitored community-based services. This is consistent with the IOP level of care that the patient received during the period under review. Therefore, the IOP services were medically necessary for 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 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.