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 individual therapy. 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 meets the criteria for weekly individual psychotherapy.For dimension 1, the patient has been at low risk of harm (score 2) due to use of alcohol to manage her emotional state though without any significant episodes of potentially harmful behaviors. The provider noted that the patient has demonstrated exacerbation of suicidal ideation or gestures in the past, but the patient recently denied these to the provider. The patient has no current suicidal or homicidal ideation plan, intentions or severe distress, but may have had transient or passive thoughts recently or in the past. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) since the patients anxiety and depression have caused her to quit college and have trouble with her general level of functioning. The patient reported that she cancelled an appointment with the provider at the last minute due to crippling anxiety. The records support that the patient has ongoing and/or variably severe deficits in interpersonal relationships, ability to engage in socially constructive activities, and ability to maintain responsibilities. For dimension 3, the patient has significant comorbidity (score 3) due to her use of alcohol to manage more difficult emotional states and stress, but with the support of therapy, has been in remission. There is evidence of recent substance use which has had clearly detrimental effects on the presenting disorder, but which has been temporarily arrested through use of a highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The records document that the patient has experienced relationship stressors with a recent breakup from a significant relationship. The patient also reports difficulty functioning in work and school due to symptoms. There is presence of some ongoing or intermittent interpersonal conflict, alienation, or other difficulties. For dimension 4B, the patients recovery environment provides limited support (score 3). The records indicate that the patient has been more isolated due to anxiety and depressive symptoms, limiting her ability to access support. There is evidence that resources may be only partially utilized even when available. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3). The patient has been in therapy for a year with significant gains though with difficulty maintaining those gains without continued strong professional support. At least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings. For dimension 6, the patient has shown positive engagement and recovery (score 2). Per the records, the patient is motivated and engaged in therapy. The patients recent anxiety symptoms have caused her to cancel an appointment with her provider, but she was previously well engaged in therapy. The patient is willing to change and is actively working toward it. These findings give the patient a composite score of 18, which is consistent with high intensity community based services, which would allow for treatment services three days per week, up to two to three hours per day. Moreover, the requested weekly individual psychotherapy sessions are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. For these reasons, the requested weekly individual psychotherapy is medically necessary for 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.