Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for intensive outpatient program (IOP) level of care. Findings:  The physician reviewer found that 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 2. The patient had some potential for risk of harm, due a history of suicidal ideation without current ideation, plan, or intent. The patient was noted as occasionally impulsive. She endorsed substance use, but without significant endangerment to self or others.  In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflictual relationships with family, inappropriate boundaries with peers, struggles in school, and problematic interpersonal relationships.With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of cannabis and alcohol use, which further exacerbated her mood symptoms, and appeared to have a significant adverse effect on her functioning and the presenting condition. 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 challenges at home, including stealing money from her parents and her grandmother, lying to her parents, cannabis and alcohol use, and conflicts with her parents. With regard to level of support of the recovery environment, the records support a score of 4 due to the patients severe conflicts with parents, with the parents significant discord and frustrations with each other. 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 an inconsistent or equivocal capacity to deal with stressors and maintain normal development, demonstrating easy dysregulation, disregard of appropriate boundaries, and not adhering to program rules. The records noted lying, stealing, and substance use.With regard to treatment acceptance and engagement, the records support a score of 3. The patient has tendencies to resist accepting even limited age-appropriate responsibility for the development, perpetuation, or consequences of her problems. Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored 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 level of care was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the service at issue were not 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.