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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for one-hour in-person sessions of intensive short-term dynamic psychotherapy twice weekly for one year. Findings:  The physician reviewer found that 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. Applying the LOCUS framework, the patient meets the criteria for one-hour in-person sessions of intensive short-term dynamic psychotherapy twice weekly for one year.For dimension 1, the patient has been at moderate risk of harm (score 3) due to continued significant suicidal ideation. The patient has been able to safety plan while in treatment and there is no reported past history of suicide attempts. The records document significant current suicidal ideation without intent or conscious plan and without past history. For dimension 2, the patient has shown moderate functional impairment (score 3) given his inability to work, sleep, or adequately perform activities of daily living. The patient is also withdrawn and isolated. The patient has demonstrated significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions.For dimension 3, the patient has significant co-morbidity (score 3) considering his chronic pain from headaches that complicate his treatment and worsen his mood symptoms. The patient also endorses use of cannabis and opioids for management of pain, but this has interacted with his symptoms and treatment. There is evidence of ongoing or episodic substance use occurring despite negative consequences with significant or potentially significant negative impact on the course of any co-occurring psychiatric disorder. For dimension 4A, the patients recovery environment has been mildly stressful (score 2). The records document that the patient has ongoing stress due to chronic pain, disability, inability to work, and financial stressors. The patient is experiencing circumstances causing some distress such as concern about maintaining material well-being. For dimension 4B, the patients recovery environment provides limited support (score 3) due to the presence of few social supports with recent relationship problems with his daughter and continued isolation from other supports. A few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3) given the patients lack of response to medications, TMS, and other psychotherapies. The patient has been unable to attain remission of symptoms. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has shown positive engagement and recovery (score 2). The provider noted that the patient is engaged and motivated for treatment despite his significant mood and pain symptoms. The patient has a positive attitude toward recovery and treatment, is capable of developing trusting relationships, and uses available resources independently when necessary. These findings give the patient a composite score of 19, which is consistent with high intensity community based services. Thus, one-hour in-person sessions of intensive twice weekly in-person psychotherapy services are medically necessary for treatment of this patient. Additionally, reviews in the medical literature have concluded that there is adequate evidence to support the use of intensive short-term dynamic psychotherapy in this patients clinical setting (Caldiroli, et al.). Furthermore, the requested intensive short-term dynamic psychotherapy is 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 requested one-hour in-person sessions of intensive short-term dynamic psychotherapy twice weekly for one year are medically necessary for 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.