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

The patient has requested authorization and coverage for weekly individual therapy sessions, or in the alternative, biweekly individual therapy sessions. Findings:  The physician reviewer found that he 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 meets the criteria for weekly individual therapy sessions. For dimension 1, the patient has been at moderate risk of harm (score 3) due to a history of binge type alcohol use and purging once every few months. She reports going for several days at a time at least twice a month where she requires little sleep or may have one night where she does not sleep at all. She has been impulsive during these times such as spontaneously driving across the country. There is some evidence of self-neglect and decrease in ability to care for herself in her current environment. For dimension 2, the patient demonstrates moderate functional impairment (score 3) given her anxiety and level of distress that has significantly increased since giving her child up for adoption. The patients anxiety is further exacerbated by the COVID-19 pandemic. There is evidence of significant disturbances in physical functioning such as sleep, eating habits, and activity level, but without a serious threat to health. For dimension 3, the patient has minor comorbidities (score 2) considering her exacerbation of psychiatric symptoms related to stress manifested by anxiety. The patient also reported headaches, poor sleep while anxious, feeling faint with rapid heartbeat, and shortness of breath. Existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. For dimension 4A, the patients recovery environment is moderately stressful (score 3) as evidenced by her placing her child up for adoption. The patient underwent 10 sessions of therapy, but her symptoms of anxiety have worsened. She has experienced side effects to standard medical therapies for PTSD and she is currently on alprazolam and scheduled hydroxyzine. The patient has significant discord or difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment provides limited support (score 3) since her parents live in Poland, her ex-spouse influenced her decision to give her child up for adoption, and she has few other supports. A few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3). The provider reports that the patient experienced partial recovery when she was referred for individual therapy in 2016. The patient has expressed hope that engagement in weekly therapy will improve her chances at recovery and functioning. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has expressed positive engagement and recovery (score 2) due to her positive attitude toward recovery and treatment. The patient is actively requesting individual therapy on a weekly basis rather than a higher level of care. She has significant understanding of her illness and its effect on her function, and she is actively trying to alleviate her symptoms. These findings give the patient a composite score of 19, which is consistent with high intensity community-based services. Based on LOCUS and the patients request for weekly services, low intensity community-based services are appropriate. This level of care provides treatment to patients who need ongoing treatment, but who are living either independently or with minimal support in the community. Treatment programming will be available up to three hours per week, but usually not less than one hour every two weeks. Based upon the review of the patients symptoms, significant trauma and ensuing escalation of symptoms and utilization of LOCUS scoring, weekly therapy is medically necessary for 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.