Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for intensive outpatient program 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 children needing mental health treatment. In this case, in terms of risk of harm, the records support a score of 2, which corresponds with some risk of harm. This is due to the patients recent self-cutting behavior and the vague suicidal ideation that she voiced around the time of her admission to the IOP. While the patient did not have suicidal ideation during the entire period that she received IOP services, she was noted to have labile moods and incongruent affect, indicating concerns that she would have a low threshold for decompensation back to self-harm and suicidal ideation. With regards to functional status, the records support a score of 3, which reflects moderate functional impairment. This is due to the patients escalated anxiety, the patients need for staff to advocate for setting up a school Individualized Education Program (IEP), and her labile moods and low threshold for decompensation back to self-harm and suicidal ideation. In terms of comorbidity, the records support a score of 2. The patient had minor co-morbidity, due to chronic anxiety and concerns for acute stress disorder or subclinical post-traumatic stress disorder after the patients ex-boyfriend imposed a series of stressors, including his own suicide attempt and breaking up with the patient. The patient also reported having been hit in the head during hockey, thereby raising concerns for concussion around this time. With regards to the level of stress of the recovery environment, the records support a score of 3, which corresponds with a moderately stressful environment. This is due to family changes, including the patients sister having moved out of the house, the patients breakup with her boyfriend and this boyfriends suicide attempt, along with worry relating to a best friend who was also reported to have suicidal ideation. In terms of the level of support of the recovery environment, the records support a score of 2, which corresponds with a supportive environment. This is due to the submitted records reflecting that the patient has supportive parents and home. With regards to resiliency and treatment history, the records support a score of 3, which reflects moderate or equivocal resiliency and/or response to treatment. This is due to the patients limited resiliency, given her history of anxiety and cutting, which was noted to have been present as far back as the 8th grade. In terms of acceptance and engagement of the patient, the records support a score of 3. The patients score reflects that the patient appeared to engage somewhat and use coping skills, but she also had challenges with medication compliance. Thus, the patient had a composite score of 18. Using the CALOCUS level of care determination grid, the recommended level of care for this composite score is Level Three: High Intensity Community-Based Services. CALOCUS level of care definitions and utilization criteria state that this level of care generally is appropriate for children and adolescents who need more intensive outpatient treatment. In this case, the patient was experiencing acute stressors and chronic anxiety, with a limited history of resiliency and psychiatric co-morbidity, which led to her need for significant mental health support during the period under consideration. Therefore, the intensive outpatient program services provided during the period under consideration were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patients 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.