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 3. The patient had a significant risk of harm, due to her young age, ongoing substance use, and engagement in high risk behaviors that put her at risk of victimization, coupled with impulsivity. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to a tense relationship with her grandparents as they attempted to set boundaries with her and struggles with peers in her treatment program. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of mental health diagnoses, cannabis use disorder, and ongoing struggles with sobriety. 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 her grandmother being described as controlling and having issues with alcohol, and her grandfather struggling to maintain consistent boundaries for the patient. The patients father continued to use cannabis, resulting in the patient having access to and relapsing on cannabis. With regard to level of support of the recovery environment, the records support a score of 3 as the patients father continued to use cannabis and discouraged the patient from attending treatment, undermining the efforts of the patients grandparents and treatment team. The patients grandfather struggled to set consistent limits with patient, which perpetuated and reinforced her manipulative behaviors, and her grandmother was noted as being excessively controlling. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment as she had a history of outpatient therapy and struggled to make progress despite having been in the IOP for approximately six months. She had relapsed upon accessing her fathers cannabis.With regard to treatment acceptance and engagement, the records support a score of 3. The patient minimized her ongoing substance use and attempted to justify her behaviors. She had limited insight and appeared resistant to accepting any responsibility for her problems.   Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored community-based services. This is consistent with the level of care that the patient received in 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 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.