Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for intensive outpatient program (IOP) services. 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 a history of extensive self-harm behaviors, multiple suicide attempts including by overdose, and substance use. During the period under review, the patient reported intense urges to use substances and to self-harm. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to a troubled relationship with her mother and challenges in stopping the use of cannabis and nicotine. Recent gains in functioning appear to have occurred while the patient was participating in treatment. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity, due to the presence of a history of cannabis and nicotine use disorder. During the period under review, the records noted continued struggles with using substances during the period under review, multiple positive drug screens, and that the patient brought cannabis vape pens to therapy sessions. 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 challenges in her relationship with her mother. The patient reports avoiding her family members to avoid arguments and struggling with guilt due to comments by her mother.  With regard to level of support of the recovery environment, the records support a score of 2 due to patients mother and stepfather actively participating in the patients treatment, although the patient continued to report a challenging relationship with her mother. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment as prior treatment has included outpatient psychotherapy, outpatient psychiatric treatment, partial hospitalization program (PHP), residential treatment center (RTC), and inpatient psychiatric hospitalization. With regard to treatment acceptance and engagement, the records support a score of 3. The patient is engaged in treatment, although she appeared ambivalent about sobriety and struggled to utilize coping skills to maintain sobriety. 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 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.