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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for individual therapy sessions weekly or every other week. Findings:  The physician reviewer found that individual therapy sessions weekly or every other week are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.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. Applying the LOCUS framework, the patient has met the criteria for individual therapy sessions weekly.With regard to risk of harm, the records support a score of 2. The patient does not have suicidal ideation but has had periods of depression in the past.In terms of function, the records support a score of 2. The patient has been struggling with depression and anxiety recently but has been able to fulfill obligations.With regard to comorbidity, the records support a score of 2. The patient has had transgender surgery and also has a history of substance misuse, although substance misuse is not currently a problem.In terms of level of stress of the recovery environment, the records support a score of 3. The patient is recently unemployed during the pandemic and has had significant strain in his relationship with his partner.With regard to level of support of the recovery environment, the records support a score of 3. The patient has few supportive resources and relies heavily on his partner for support, although this is also a strained relationship.In terms of treatment and recovery history, the records support a score of 3. The patient does better when receiving structured therapeutic support, although he has trouble maintaining this.With regard to engagement, the records support a score of 3. Although the patient says that hes eager to be connected to more frequent treatment, hes missed three sessions in the last months without cancelling and at times, has trouble accepting responsibility for his recovery.These findings give the patient a composite score of 18, which is consistent with high intensity community-based services or intensive outpatient services. For these reasons, weekly individual therapy sessions are medically necessary for the treatment of this patient. Additionally, weekly individual therapy sessions are clinically appropriate in terms of type, frequency, extent, site, and duration. Weekly individual therapy sessions 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 individual therapy sessions weekly are medically necessary for treatment of the patients medical condition.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.