Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient 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, the patient met the criteria for the medically monitored community-based services and therefore the IOP services were medically necessary for the treatment of this patient. For dimension 1, the patient was at some risk of harm (score 2) due to a history of suicidal ideation with a plan to jump out a window. The patient does not have a reported history of suicide attempt. The patient has a history of self-harm and carrying a knife. The records document a past history of fleeting suicidal or homicidal thoughts with no current ideation, plan, or intention and no significant distress. For dimension 2, the patient demonstrated moderate functional impairment (score 3) considering his expulsion from school after he threatened a peer with a taser, became physically aggressive, and made a bomb threat. The provider noted that the patient also struggled with motivation, excessively played video games, and lacked in engagement in prosocial activities including socializing with peers. The patients school behavior deteriorated to the point the patient has faced school disciplinary action and is at risk for placement in an alternative school program or repeating their grade. For dimension 3, the patient has significant co-occurrence (score 3) given his diagnosis of ADHD, which is a neurodevelopmental disorder and can contribute to mood dysregulation, anger dyscontrol, and poor decision making. The patient also has a history of a learning disorder for which he was in special education for many years. A developmental disability is present that may adversely affect the presenting condition and/or may require significant augmentation or alteration of treatment for the presenting condition or co-morbid condition, or adversely affects the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The records document that the patients sister has a history of substance abuse and suicide attempt. The patients mother is often out of town for long periods of time. The patient was bullied at school and subsequently expelled after he made threats and became aggressive. The patient reported that his father relapsed in the last six months after a long period of sobriety, and he feels pressure about turning 18. There is evidence of disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3). The provider noted that the patient described his relationship with his parents as superficial. The patients mother is often out of town for long periods of time and his parents struggle to co-parent effectively, implement and enforce home rules, and have difficulty taking responsibility for their decisions. The records indicate that the patients family has limited ability to respond appropriately to the patients developmental needs and problems or is ambivalent toward meeting these needs or addressing these problems. For dimension 5, the patient exhibited moderate or equivocal resiliency and/or response to services (score 3). The records suggest that prior treatment has been limited to outpatient psychiatric care including psychotropic medication. The patient was previously in an IOP for approximately five months prior to this admission. Thus, previous treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient showed limited engagement in services (score 3) since the patient was noted to be eager to make changes, but he also struggled with realistic planning, excessive need for control, and he repeatedly argued against the terms of the behavioral contract he entered into with his parents. The patient also struggled with rigid thinking. The patient acknowledged the existence of a problem but resisted accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 20, which is consistent with Level 4 medically monitored community-based services. Moreover, the IOP services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration and were not primarily for the convenience of the patient or provider. All told, the IOP services were medically necessary for 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 subspecialty 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.