Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for intensive outpatient program (IOP) services (three visits). 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 risk of harm, due to mild suicidal ideation, without intent, conscious plan, or a history of suicide attempts. Overall, the patient appeared to have ruminations and distress over needing to die. She reported mild suicidal ideation, triggered by her recent birthday and her memory of telling herself a year previously that she would die by the time she was 15. The records noted risk factors for suicidal behaviors, including symptoms of depression and anxiety such as dysphoria, low self-esteem, and feelings of helplessness.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient presented as conflicted, withdrawn, and with troubled family relationships. Ruminating on self-harm urges appeared to be impacting the patients ability to enjoy social activities such as watching a movie and maintaining safety in general. The records noted an academic decline in grades from As to Bs and Cs. The patient appeared to have inhibitions around telling her parents about her self-harm urges, indicating poor communication skills, and appeared to be overwhelmed with anxious thoughts about a friend who was hospitalized. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to minimal developmental delay, disorder, or brain dysfunction, without substance use issues or medical problems.  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 significant familial turmoil as her father had left the family for another woman. The patient has experienced interpersonal loss that has had significant impact on the child and family. With regard to level of support of the recovery environment, the records support a score of 3 due to only a partial ability of the patients caregivers to make necessary changes during treatment. When reported that she thought her father secretly had married his partner, her father appeared to stay quiet and did not confirm or deny this concern. Overall, the familial relationships appeared to be challenging and unpredictable in terms of ability to provide a secure base. In terms of resiliency and treatment history, the records support a score of 3. The patient had a moderate or equivocal response to treatment due to an inconsistent  capacity to deal with stressors and maintain normal development. Despite outpatient therapy, the patient continued to struggle with significant symptoms of anxiety and depression including vague suicidal ideation and self-harm urges.With regard to treatment acceptance and engagement, the records support a score of 2. The patient seemed to be able to develop a trusting, positive relationship with clinicians and other care providers. Thus, the patient has a total score of 18. In this case, the recommended level of care is high intensity 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 (three visits) 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.