Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested reimbursement for intensive outpatient program (IOP) services provided by Sundance Canyon East Academy. 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.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 suicidal thoughts and of self-injurious behaviors since age four. In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to intermittent struggles with peers and following expectations at home. He showed evidence of minor failures of function in interacting with family and peers. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to the presence of mental health diagnoses of depression and anxiety, attention deficit hyperactivity disorder (ADHD), and substance use disorder. The patients ADHD contributes to his impulsivity and mood dysregulation and his autism likely plays a role in cognitive rigidity, which further contributes to mood dysregulation leading to angry outbursts and aggressive behaviors. 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 the biological mothers substance use and mental health issues resulting in the patient living with the father. The records noted that the patient held resentment towards the father and stepmother, blaming them for having to move out of the patient's mothers home.With regard to level of support of the recovery environment, the records support a score of 2 due to the patient's parents willingness and ability to seek out and participate in treatment for their son. 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 included outpatient psychotherapy, outpatient psychiatric treatment, and a therapeutic wilderness program, indicating that the patient struggled to deal with stressors and maintain normal development and that the patient's recovery was maintained only with strong support. With regard to treatment acceptance and engagement, the records support a score of 2. The patient was able to engage in treatment.Thus, the patient has a total score of 17. In this case, the recommended level of care was 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 provided by Sundance Canyon East Academy 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.