Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested reimbursement for intensive outpatient program (IOP) services. 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, the patient met the criteria for the IOP services. For dimension 1, the patient was at some risk of harm (score 2) due to a history of suicidal ideation. During the period under review, the patient made threats of suicide when upset after being confronted by staff. The patient does not have a history of attempting suicide. The patient has endorsed use of substances on multiple occasions. The patient has a history of self-harm but had not engaged in self-injury since being admitted to the program. The patient also snuck out of home to meet boyfriend. The patient demonstrated mild suicidal ideation with no intent or conscious plan and with no past history. For dimension 2, the patient demonstrated moderate functional impairment (score 3). The records indicate that during this admission, the patient struggled with completing school assignments and refused to attend school due to panic attacks. The patient reported having engaged in stealing with a peer. There is documentation of conflicted, withdrawn, or otherwise troubled relationships with peers, adults, and/or family, and recent gains and stabilization in functioning have been achieved while participating in treatment in a structured treatment program. For dimension 3, the patient has minor co-occurrence (score 2) given a history of substance use and used substances multiple times while in treatment. The records do not indicate a pattern of escalating substance use. There is report of occasional, self-limited episodes of substance use that show no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patient continues to struggle with the fathers death, which occurred in 2018 due to alcohol-related complications. School assignments and where to attend school in the future was a stressor. The patients mother was noted to be anxious and frustrated about the patients academic difficulties. There was disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3) given the mothers struggles with parenting effectively. The patients mother demonstrated difficulties implementing consequences for the patient due to fear of backlash and regression. The patients family has limited ability to respond appropriately to the patients developmental needs and problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to services (score 3). Prior treatment has included outpatient treatment and nine months of IOP. The patient has demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development. The patient demonstrated limited ability to follow through with treatment recommendations. For dimension 6, the patient demonstrated limited engagement (score 3). The records indicate that patient participated in treatment but struggled with accepting accountability for behaviors and became resistant towards support or feedback from the providers. The records indicate that the patient was unwilling to receive feedback. The patient had ambivalent, avoidant, or distrustful relationships with clinicians and other care providers. These findings give the patient a composite score of 19, which is consistent with Level 3 high intensity community-based services. In addition, the IOP services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the IOP services were medically necessary 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.