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 psychotherapy. 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, due to a history of cannabis use that negatively impacted her psychiatric symptoms and ability to function.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient was on a medical leave from her job to address her psychiatric symptoms. Any gains in her ability to function were limited to when she was participating in structured treatment. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to chronic pain and upcoming surgery.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 transitions in her life circumstances including breaking up with her partner and her partner moving out of their apartment, and coming out to her family, which she described as challenging. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has few supportive resources due to transitions in her relationships. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, as previous 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 2. The patient has a positive engagement history with a strong willingness and motivation to participate in treatment.Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. In this patients case, weekly individual psychotherapy 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, weekly individual psychotherapy is 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.