Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the intensive outpatient program services provided from the end of October of 2018, going forward.  The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees intermittent explosive disorder and bipolar II disorder.At issue in this case is whether the intensive outpatient program services provided from the end of October of 2018, going forward are medically necessary for treatment of the enrollees behavioral health condition.In cases such as this, an evidence based instrument such as the CALOCUS (Child and Adolescent Level of Care Utilization System) is indispensable for determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible.  1.Risk of harm--- none (1), this is due to the patients lack of current self-harm ideation.2.Functional status--- minimal (1), the enrollee has had some deterioration and expected level of functioning in relationships with family and overall is functioning well according to the records.3.Co-Morbidity---mild (2), the enrollee does not have active serious medical problems or substance use that is active.  He has an opiate use disorder diagnosis.4.A) Recovery environment, level of stress---mild (2), the enrollee has issues with family relationships family but has a stable housing situation.B) Recovery environment, level of supporthighly supportive (1), the enrollees family is actively involved in treatment and attend family therapy sessions on a regular basis.5.A)  Resiliency and Treatment historyequivocal (3), this is due to apparent success in the IOP but unclear success with past treatment.B) Acceptance and engagement, child/adolescent---constructive (2), the enrollee participates actively in therapy. 6.Acceptance and Engagement, Parent ---constructive (2), the parents work actively and constructively with clinicians. This gives the patients presentation a composite score of 14. A score of 14 correlates with a treatment intensity level of two which correlates with `Outpatient Services`.  This score is judged by the acuity of the patients symptoms and environment during the period under dispute, as of the date of denied health plan authorization. Outpatient treatment and least restrictive option are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry. It is recommended that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports.  The documentation indicates the patient entered IOP due to anger, irritability and past history of suicidal ideation. His family was engaged in therapy with him on a regular basis.   Progress notes indicated that he was engaging well with peers and reported a good mood. It is noted that he had power struggles with his family.  He did not express any suicidal ideation, and their records did not mention substance use.  There was no indication of serious medical issues or behavioral issues at school.  He presented as happy and cooperative with his individual and group therapy sessions. He was able to verbalize improvement in his relationships with family, as well as with his target symptoms.  The progress notes did not indicate that the patient was suffering from severe functional impairment.  The records did not document school issues.Recommendations for the treatment of intermittent explosive disorder include suggestions that clinicians treat intermittent explosive disorder with pharmacotherapy plus cognitive-behavioral therapy (CBT). CBT teaches patients to anticipate and better manage aversive environmental stimuli and may thus prevent aggressive impulses.  Due to the patients lack of other acute mood, anxiety psychotic, self-harm, and no harm towards others, CBT could be provided on an outpatient basis. Therefore, the intensive outpatient program services from the end of October of 2018, going forward are not medically necessary.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.