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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for four to six weeks partial hospitalization program (PHP), minimum three hours per day, three days per week, in a program that includes exposure response prevention as the frontline treatment. 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 1. The patient has a low potential for risk of harm as the records do not document suicidal ideation or of self-harm. In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to increased isolation due to of shame about her symptoms, but reports that she is still volunteering, in a relationship, and in an internship.  With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity due to COVID-19 in the beginning of this year, pelvic pain, and intimacy issues.  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 isolating themselves and feeling performance pressures related to school. With regard to level of support of the recovery environment, the records support a score of 2 as the patient has a small but reliable support system of family and partner with whom they live.  In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as they have been in treatment since childhood with previous treatment not achieving remission of their symptoms.  With regard to treatment acceptance and engagement, the records support a score of 3. The patient has declined resources for and takes limited responsibility for their recovery.  Thus, the patient has a total score of 16. In this case, the recommended level of care is low intensity community-based services. In this patients case, PHP level of care is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, four to six weeks PHP, minimum three hours per day, three days per week, in a program that includes exposure response prevention as the frontline treatment is not medically necessary for the 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.