Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an Intensive Outpatient Program (Cognitive Behavioral Therapy, Behavior Intervention, Occupational Therapy, Speech Therapy, Small Group Social Skills Therapy, and Intensive Parent Training) 3 hours a day, 5 times a week, for 30 to 60 days.The submitted documentation does not support that the requested Intensive Outpatient Program is medically necessary. The patient has a complicated behavioral health and medical history that consists of issues related to anxiety as well as developmental delays. While the patient is stated to be a safety concern, the submitted documentation does not provide objective evidence of any self-harm behaviors. Concern for self-harm was described because of tantrum type behavior as well as the patient throwing himself on the ground. There is no indication, however, of purposeful self-harm behavior, but rather a potential for self-harm due to behavior tantrums. The submitted documentation also reflects that the patients family is very involved in his treatment and that there is no indication of an unsafe living environment or of substance use.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 terms of risk of harm, the records support a score of 2. This is due to the patients episodic impulsive outbursts. The patient is not having active suicidal ideation or other behaviors or thoughts that would warrant a higher score in this category. With regards to functional status, the records support a score of 2. While the patient has had deterioration in functioning, there is minimal objective evidence to support this. In terms of comorbidity, the records support a score of 1. The patient did not have any active serious medical problems or active substance use issues. With regards to level of stress of the recovery environment, the records support a score of 1, as the patient has no mention of significant enduring difficulties of an environmental nature. In terms of level of support of the recovery environment, the records support a score of 1, for the patients family is actively involved in treatment, and treatment resources are readily available. With regards to resiliency and treatment history, the records support a score of 0 (not scored). While observation notes indicate cooperation in occupational therapy, there is otherwise no description of the patients response to previous treatment or of objective evidence to support treatment outcomes. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient participates actively in occupational therapy, and there is no indication of therapy refusal of other types. With regards to acceptance and engagement of the parent, the records support a score of 2. Records reflect that the patients parents work actively and constructively with clinicians. Thus, the patient had a composite score of 11. This score correlates with a treatment intensity level of care of Level 1, which correlates with Recovery Maintenance and Health Management. Therefore, the requested Intensive Outpatient Program (Cognitive Behavioral Therapy, Behavior Intervention, Occupational Therapy, Speech Therapy, Small Group Social Skills Therapy, and Intensive Parent Training) 3 hours a day, 5 times a week, for 60 days, is not medically necessary for the treatment of the patients medical condition. In addition, the requested Intensive Outpatient Program (Cognitive Behavioral Therapy, Behavior Intervention, Occupational Therapy, Speech Therapy, Small Group Social Skills Therapy, and Intensive Parent Training) 3 hours a day, 5 times a week, for 30 days, is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.