Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that 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, the patient met the criteria IOP services. For dimension 1, the patient was at significant risk of harm (score 3) due to an extensive history of suicidal ideation and suicide attempts. The patient denied current suicidal ideation. The patient has a history of running away, and threatened to run away during treatment stay. The records document no active suicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient demonstrated mild functional impairment (score 2) given rule breaking behaviors, even while in treatment. The patient reported having a troubled relationship with parents. The patient struggled to accept limits placed by parents and the treatment program. On admission, the patient was frequently truant from school and was behind academically. There is some evidence of minor failures of function in any of several areas of living such as school, family, peers. These periodic or momentary failures were time limited. For dimension 3, the patient has minor co-occurring conditions (score 2). The records document that the patient was admitted with a substance use disorder. The patient abstained from using substances during time in treatment, likely in part due to regular urine drug screens and the support of treatment. Occasional, self-limited episodes of substance use were present that showed no patterns of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment was moderately stressful (score 3) given the patients longstanding family issues. The provider noted that there was stress between the patient and mother, which continued throughout the stay in IOP. The patient indicated that the mother belittled the patient, and was upset due to fathers absence. The patient worked to avoid anger and to avoid punishment. There is evidence of disruption of family and social milieu. For dimension 4B, the patients recovery environment provided limited support (score 3). The records document that the patient did not feel emotionally supported by parents. The patient reported that the mother was unable to provide emotional support, and mother had trouble setting firm boundaries with the patient. The patient reported feeling pressure from father. The patients family demonstrated only partial ability to make necessary changes during treatment. For dimension 5, the patient demonstrated moderate or equivocal resiliency and response to treatment (score 3). The records provide little information regarding prior treatment, but the patient had a psychiatrist prior to admission. The patient struggled during follow through with treatment recommendations and demonstrated an inconsistent or equivocal capacity to deal with stressors and maintain normal development. For dimension 6, the patient exhibited limited engagement in services (score 3) due to reports that the patient was stagnant and made decisions despite staff directions. The patient utilized lying, manipulating, and avoidance to get their way during treatment. The patient also struggled to ask for help. The patient frequently did not follow the service plan. These findings give the patient a composite score of 19, which is consistent with Level 3 high intensity 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 not primarily for the convenience of the patient or provider. For these reasons, 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.