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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for weekly therapy appointments and monthly psychiatry appointments. 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 3. The patient has a significant risk of harm, due to recent hopelessness and passive suicidal ideation without current intent or plan and without a history of suicide attempts. In terms of functional status, the records support a score of 2. The documentation noted mild impairment due to the patient some struggles in functioning with minor disruptions in usual activities.  With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of fibromyalgia, chronic pain, and cannabis use, complicating treatment. 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 recent stressors, mainly around her chronic pain and psychiatric symptoms, and continued substance use. With regard to level of support of the recovery environment, the records support a score of 2 as the patient is able to access support from immediate family and boyfriend. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatments due to continued depressive symptoms without significant improvement.With regard to treatment acceptance and engagement, the records support a score of 3. The patient has had challenges with maintaining engagement, as the records noted that the enrollee did not follow up on assignments from therapy and left an RTC against medical advice.  Thus, the patient has a total score of 18. In this case, the recommended level of care is high intensity community-based services. In this patients case, weekly therapy appointments and monthly psychiatry appointments 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, weekly therapy appointments and monthly psychiatry appointments 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.