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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for individual, one-on-one intensive outpatient program (IOP) therapy. Findings:  The physician reviewer found that 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 met criteria for a higher level of care than IOP. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to repeated endorsement of suicidal ideation, describing a plan of overdose on pills and being referred to the hospital for suicidal ideation during the course of this treatment. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflicted relationships with his parents, especially his father, and difficulty functioning due to poor energy and sedation from medication. With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity due to poor energy and sedation from medication.In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to a conflicted relationship with his father, and reports isolating. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has few supportive resources, with conflicted relationships with his family. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, as he has been referred for hospitalization for suicidal ideation in the course of this treatment, has had trouble with group psychotherapy in the past, and has not achieved remission of his symptoms. With regard to treatment acceptance and engagement, the records support a score of 3. The patient is motivated for treatment but presents often as tired and groggy, inserting variability into this engagement. Thus, the patient has a total score of 21. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. This is a higher level of care than the requested individual, one-on-one IOP therapy. In this patients case, individual, one-on-one IOP therapy is 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, individual, one-on-one IOP therapy are medically necessary for the treatment of this patientFinal 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.