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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for residential treatment center services, which include more than 18 hours of individual sessions per week in residential treatment center along with eye movement desensitization reprocessing (EMDR) therapy and neurofeedback for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that Based on the Level of Care Utilization System (LOCUS) criteria and clinical documentation submitted for review, the patient meets criteria for a portion requested services. The patients risk of harm score is three (3), moderate risk of harm. The documentation indicates that the patient has had three to four prior suicide attempts but that the patient would not discuss them. The patient has chronic suicidal ideation with no plan. The patients functional status score is four (4), given the patients serious impairment. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient had a co-morbidity of major depressive disorder, OCD, PTSD, and panic disorder with agoraphobia. The patients recovery environment score is four (4), highly stressful environment.  The patients level of support score is three (3), limited support in environment. The patient only has support from the patients mother and partner. The patients treatment history score is four (4), poor response to treatment and recovery. The patients provider reported that the patient has not responded well to medications and recommends a RTC level of care. The patients symptoms have worsened over the past several years. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient wants to get better and engage in treatment. Based on these criteria, the patient has a total score of 23 and meets criteria for treatment at a RTC level of care. The documentation demonstrates that the patient is severely impaired due to panic disorder, depression, and agoraphobia. In addition, the request for 18 hours per week of individual therapy is appropriate and medically necessary as this is standard amount of treatment in a RTC setting. EMDR is evidence based treatment for PTSD and is medically necessary. However, there is a lack of support in the peer-reviewed literature for neurofeedback in this clinical setting. All told, the request for RTC services, which include more than 18 hours of individual sessions per week in RTC along with EMDR therapy is medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.