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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensive outpatient program (IOP) services.  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, this patient does not meet the criteria for IOP services. For dimension 1, the patient has been at low risk of harm (score 2) due to a lack of current suicidal or homicidal ideation. The patient does not have current suicidal or homicidal ideation, plan, intentions, or severe distress, but may have had transient or passive suicidal ideation recently or in the past. The records available for review consistently indicate no suicidal ideation. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) considering the patients significant in physical functioning such as sleep, eating habits, activity level, or sexual appetite, but without a serious threat to health. Specifically, the patient reports significant sleep disturbance and difficulties with physical activity. For dimension 3, the patient has significant comorbidity (score 3) due to the patients primary diagnosis of PTSD secondary to severe trauma as well as major depressive disorder and generalized anxiety disorder. This combination of diagnoses impacts the patients primary psychiatric disorder to a significant extent. The records suggest that medical conditions exist or have the potential to develop, which may require significant medical monitoring. For dimension 4A, the patient is in a low stress recovery environment (score 1). The records document that the patients material needs are met without significant cause for concern that they may diminish in the near future, and no significant threats to health or safety are apparent.   For dimension 4B, the patients recovery environment has been supportive (score 2). The provider noted that the patient has supportive resources that are not abundant but are capable of and willing to provide significant aid in times of need. The patient has engaged with available professional supports. For dimension 5, the patient has exhibited significant response to treatment and recovery management (score 2) since previous or current experience in treatment has been successful in controlling most symptoms but intensive or repeated exposures may have been required. The records suggest that the patient has not received inpatient or outpatient treatment prior to enrollment in the current IOP. The patient required intensive exposure to the current treatment, with 48 sessions over five months, to reach his currently level of recovery. For dimension 6, the patient has shown positive engagement and recovery (score 2). As documented in the chart, the patient has significant understanding and acceptance of illness and its effect on function. The patient is willing to change and is actively working toward it (Action Stage). Also, the patient has a positive attitude toward recovery and treatment, can develop trusting relationships, and uses available resources independently when necessary. The patients total LOCUS score is 15, is consistent with low intensity community-based services. Moreover, the requested IOP services are not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the requested IOP services are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 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.