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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for psychotherapy services once every two weeks for at least four months.Findings:  The physician reviewer found that 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. With regard to risk of harm, the records support a score of 1. The patient has a low risk of harm, without suicidal ideation or a history of suicidality.  In terms of functional status, the records support a score of 2. The documentation notes mild functional impairment due to some recent stressors, making functioning more difficult, but the patient is able to maintain overall functioning and relationships. With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity due a recent referral to dermatology for a skin lesion on skin that had grown. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient has a mildly stressful environment due to a conflicted relationship with her father following the death of her mother when the patient was 19 years old.  The patient reports recent stress and triggers for her worsening mood.  With regard to level of support of the recovery environment, the records support a score of 3 as the patient has a strained relationship with her father. The patient lacks professional sources of support, seeking therapy or counseling repeatedly recently for worsening symptoms. In terms of resiliency and treatment history, the records support a score of 2. The patient has significant resiliency and/or response to treatment, as she maintained stability following psychiatric treatment until recently. With regard to treatment acceptance and engagement, the records support a score of 2. The patient is engaged and motivated for treatment, seeking out resources and demonstrating a willingness to change if given the right resources.Thus, the patient has a total score of 14. In this case, the recommended level of care is low intensity community-based services. In this patients case, psychotherapy services once every two weeks for at least four months are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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, psychotherapy services once every two weeks for at least four months are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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 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.