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

At issue in this case is whether the IOP services three (3) days a week, or IOP services five (5) days a week going forward, were and/or are medically necessary. The most recent progress notes from the patients intake evaluation indicate that the patient was functioning well overall with mild symptoms. The progress notes indicate that the patient recently completed a two month IOP program. The most recent progress notes do not indicate that the patient is experiencing any suicidal ideation and she reported no substance use for one month. Her impulse control was noted to be good and the progress notes did not reflect mood swings or other impulsive behaviors in the recent past. Applying the Level of Care Utilization System (LOCUS) from the American Association of Community Psychiatrists, this patient does not meet the criteria for IOP level of care services. Using LOCUS, treaters 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. The records indicate that this patient is at low risk of harm (score 2) due to a lack of current suicidal ideation with a history of passive suicidal ideation and prior suicide attempt. The patients functional status is mildly impaired (score 2) due to some interpersonal issues and minor disruptions in activities of daily living. The patient has minor comorbidities (score 2) given her overall medical stability with some substance abuse issues that are described as under control. The patients recovery environment is mildly stressful (score 2) as she has a stable living environment and her recovery environment is supportive (score 2). The patient has demonstrated significant treatment response in the previous IOP that she completed (score 2). Further, the patient has been positive and engaged in her treatment (score 2) with good cooperation and participation. This gives the patients presentation a composite score of 14. This score correlates with a treatment intensity level of two, which is consistent with low intensity community based services. An example of a level two placement per the LOCUS, is clinic-based services without frequent contact. Given these findings, the IOP services three (3) days a week (that includes: two 1.5 hour group therapy sessions three days a week, three DBT group therapy sessions, one cognitive behavioral therapy (CBT) group therapy session, one seeking safety group therapy session (for trauma, self-harm, and substance abuse), one recovery skills group therapy session (for substance abuse), one one-hour DBT session, and 10 minutes of DBT phone advice per week); and/or increasing the IOP services to five (5) days a week (that includes: two 1.5 hour group therapy sessions three days a week, three DBT group therapy sessions, one CBT group therapy session, one seeking safety group therapy session (for trauma, self-harm, and substance abuse), one recovery skills group therapy sessions (for substance abuse), 1 one-hour individual DBT session, and 10 minutes of DBT phone advice per week), going forward, were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were not and 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 sub-specialty 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.