Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Intensive Outpatient Program (IOP) services.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.For dimension 1- risk of harm. This dimension assesses potential for harm to self or others. The patient continued to struggle with auditory hallucinations and profound persecutory and erotomanic delusions throughout her treatment in the Intensive Outpatient Program (IOP). Notes indicate that the patient had command auditory hallucinations with suicidal ideation and affective dysregulation. She continued to have significant affective dysregulation, delusions, auditory hallucinations and episodes of agitation. In one instance, 911 was called as the patient had to be restrained by her husband due to agitation. These behaviors reflect that the patient has been at moderate risk of harm. [Score 3  Moderate Risk of Harm]For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with, maintain physical functioning and capacity for self-care. The patient is on disability from work and is unable to fulfill work obligations. She continues to have significant disturbances in sleep and in her ability to communicate without becoming agitated or dysregulated. These deficits and limitations correspond with moderate impairment in functional status. [Score 3  Moderate Impairment]For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient has no co-morbid illnesses that are active and contributing to her presentation during the time in question. [Score 1  No Co-Morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patient's recovery environment is moderately stressful due to significant discord in the patients marital relationship and her separation from her husband in the course of this treatment. [Score 3  Moderately Stressful Environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the recovery environment. The patients recovery environment was supportive despite being limited due to marital discord and lack of other meaningful, supportive relationships. The patient utilizes the supports from professionals and treatment effectively. [Score 2  Supportive Environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient's psychotic symptoms are noted to be refractory, and the patient has been noted to have failed at least three antipsychotic medications and discussed the possibility of clozapine treatment. While the patient has attained partial recovery over moderate periods of time, this has only been with strong professional support in a structured setting. [Score 3  Moderate or Equivocal Response to Treatment and Recovery Management]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and ability and willingness to engage in the treatment process. The patient has positive engagement and recovery, with a positive attitude toward treatment. The patient is noted to be invested in utilizing treatment to progress in her recovery. [Score 2  Positive Engagement and Recovery]These findings give the patient a composite score of 17, which is corresponds with Level 3, High Intensity Community-Based Services. Level 3 is consistent with an Intensive Outpatient Program (IOP) level of care. Accordingly, the Intensive Outpatient Program (IOP) services at issue and requested services were, and are, medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.