Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services.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. The patient had significant risk of harm due to a significant history of destructive acts in the home including aggression towards parents and property destruction. Given the patients history of ADHD issues with poor impulse control, substance use, and also pre-morbid anxiety concerns, the patients risk of harm was significant. The patient appeared to require extra support for skills development to assist in managing low frustration tolerance, irritability, anger, and drug cravings. In terms of functional status, the records support a score of 3. The patient had moderate functional impairment due to poor school performance, severe parent-child relational problems involving verbal and physical aggression within the home, and relationship difficulties with friends. With regard to comorbidity, the records support a score of 3, to reflect significant co-morbidity. The patient had alcohol dependence and cannabis dependence, parent-child relational conflicts, ADHD, and significant anxiety symptoms that were concerning for generalized anxiety disorder. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful home environment due to concerns for conflictual family dynamics. With regard to the level of support of the recovery environment, the records support a score of 2. The patient had a supportive environment as his parents appear to be making efforts to support him. In terms of resiliency and treatment history, the records support a score of 4, as the patient had poor resiliency and/or response to treatment. The patient was following with a psychiatrist prior to receiving IOP services, but with limited effectual change in functioning. With regard to treatment acceptance and engagement of the patient, the records support a score of 3. The patient had incomplete engagement, as notes indicate that he relapsed three times on substances and also was disengaged at times during telehealth appointments. Thus, the patient has a total score of 22. The records support Intensive Outpatient Program level of care in this setting. Therefore, the Intensive Outpatient Program (IOP) services at issue were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the patient's 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.