Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for intensive outpatient program (IOP) services provided at Insight Treatment Program. 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 meets 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, without attempted suicide or self-harm. The records noted that the patient has threatened to kill his mother and been physically aggressive to her. The records noted anger dyscontrol, suggesting poor impulse control. Although he exhibited improvement during treatment, the records indicate that he continued to struggle with regulating his mood and controlling his anger. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to the patients continued difficulty managing anger, ongoing problems in his relationships with his mother, verbal altercations with peers, and stealing from peers. While in IOP, he made little academic progress. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to the records noting that he vaped to manage distress. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to a long history of exposure to domestic violence and a history of being abused. The patients father struggled with substance abuse and his mother struggled with a binge eating disorder. The patient had a highly conflictual relationship with his mother, and the records noted an episode in which the patients mother gave the patient pills, which he ingested, and told him to kill himself. The patient reported that his mother consumed alcohol and was verbally abusive. During the period under review, his relationship with his mother remained problematic. With regard to level of support of the recovery environment, the records support a score of 4 as his mother is described as having difficulty connecting, communicating, and parenting in a healthy way. The records described the patients home as consisting of mistrust, dysregulated emotions, maladaptive coping skills, and trauma response behaviors. The patient reported that his mother was not willing to listen to him and that he felt dismissed.In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment with prior treatment, including outpatient psychotherapy for one and a half years and outpatient psychiatric treatment for seven years, along with psychotropic medication. With regard to treatment acceptance and engagement, the records support a score of 3. The patients mother was inconsistent in her participation. Thus, the patient has a total score of 22. 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 services provided at Insight Treatment Program 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.