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 extreme distress and a history of suicidal ideation without active suicidal or homicidal ideation.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to chronic, severe deficits in interpersonal relationships, but with the ability to engage in socially constructive activities and to maintain responsibilities. His recent gains and stabilization in functioning have been achieved while participating in treatment in a structured, protected, and/or enriched services such as the IOP. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of polysubstance abuse including alcohol, cannabis, and nicotine, and psychiatric disorders including major depressive disorder, anxiety, and attention deficit hyperactivity disorder (ADHD). 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 his mother undergoing treatment of cancer, resulting in a serious drop in capacity of his parent. With regard to level of support of the recovery environment, the records support a score of 3 due to his family having a limited ability to respond appropriately to the patients problems and demonstrating only a partial ability to make changes during treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as prior treatment has included inpatient treatment, residential treatment, psychiatric care, and psychiatric medications without achieving remission or optimal control of symptoms. The patient demonstrated frequent of evidence of innate vulnerability under stress and difficulty resuming progress toward expected developmental level. With regard to treatment acceptance and engagement, the records support a score of 4. The patients family often refused to engage in therapeutic discussions and actively refused to comply with recommended treatment. Thus, the patient has a total score of 23. In this case, the recommended level of care is medically monitored residence-based services. This is a higher level of care than what 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.