Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parents of an enrollee has requested reimbursement for behavioral health intensive outpatient program (IOP) level of treatment services provided from 5/19/21 through 6/30/21.At issue in this case is whether behavioral health IOP level of treatment services provided from 5/19/21 through 6/30/21 were medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) 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.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. Using CALOCUS, 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) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, the patient met the criteria for IOP services provided from 5/19/21 through 6/30/21.With regard to risk of harm, the records support a score of 2. The patient has one prior suicide attempt by attempting to choke herself. Prior to admission, the patient had recurrent suicidal thoughts and she continued to endorse passive suicidal throughout treatment, indicating some risk of harm.In terms of functional status, the records support a score of 3. Prior to IOP, patient was not attending school. Records suggest that she resumed attending school while in treatment. This suggests a recent gain in functioning that was achieved while participating in treatment. The patient continues to be easily overwhelmed, is noted to be excessively reliant on her mother for emotional support and anxiety management, and continues to exhibit avoidant behaviors.With regard to comorbidity, the records support a score of 3. The patient has no medical problems. However, in addition to depression, she struggles with significant anxiety, indicating significant comorbidity.In terms of level of stress of the recovery environment, the records support a score of 3. The patients recovery environment is moderately stressful due to conflict with her father whom the patient finds unsupportive. The patients parents are divorced. This suggests a moderately stressful environment.With regard to level of support of the recovery environment, the records support a score of 3. Although the patients parents appear to be engaged in their daughters treatment, records indicate that the patient has conflict with her father. This suggests that her parents demonstrate only partial ability to make necessary changes during treatment.In terms of resiliency and treatment history, the records support a score of 4. The patient has shown poor response to treatment and recovery management. Previous treatment includes outpatient counseling in elementary school and then returned to counseling in 2019, attending twice weekly. Despite over three months of IOP treatment, the patient continued to struggle with significant anxiety symptoms, negative self-talk, and continued to express ongoing passive suicidal ideation. This suggests poor resiliency and response to treatment.With regard to treatment acceptance and engagement, the records support a score of 3. The patient appeared to be engaged in treatment as evidence by her attendance in individual, group, and family therapy, but records note that she struggled to participate in groups due to anxiety. This suggests incomplete engagement as the patient continued to exhibit avoidant behaviors in her relationship with treatment providers.Thus, the patient has a total score of 21, which is consistent with Level 4 Medically Monitored Community Based Services. For these reasons, behavioral health IOP level of treatment services provided from 5/19/21 through 6/30/21 were medically necessary for treatment of this patient. Additionally, the services at issue were in accordance with the generally accepted standards of mental health and substance use disorder care. 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.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.