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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly outpatient/telehealth counseling services. 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, as the patient reported current suicidal ideation without intent or conscious plan and without past history. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the submitted records documented that the patient has been conflicted and unable to form or maintain therapeutic relationships. The patient is recently conflicted, withdrawn, alienated, or otherwise troubled in most significant relationships, but maintains control of any impulsive, aggressive, or abusive behaviors.With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity due to the presence of a diagnosis and treatment for lymphoma, laminectomy, and six months of chemotherapy, along with reports of peripheral neuropathy and a foot drop. The patient reported that his postoperative course was painful and traumatizing. The patient has medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. 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 stress from transitioning from job searching.With regard to level of support of the recovery environment, the records support a score of 2. The patient has a supportive environment due to access to psychiatric and psychological support. Some elements of the support system are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes.In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, as the records reported a history of full remission from major depressive disorder. The patient has since experienced multiple losses, a lymphoma diagnosis and treatment, and reported worsening of mood symptoms with suboptimal response to treatment.  The patients current treatment has not achieved complete remission of symptoms or optimal control of symptoms.With regard to treatment acceptance and engagement, the records support a score of 3. The patient has become disengaged from the psychiatric treatment providers reports frustration with the system. The patient relates to treatment with some difficulty and establishes few, if any, trusting relationships.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 outpatient/telehealth counseling services 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 outpatient/telehealth counseling services 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.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.