Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 24-year-old male with a history of persistent depressive disorder and generalized anxiety disorder. The patient reported that he has been depressed since middle school. He reported that he was consuming alcohol as a coping method. The records indicate that he was anxious, depressed, and irritable. The patient was admitted to an intensive outpatient program and was treated with psychotherapy and psychopharmacology. The patient requested reimbursement for mental health intensive outpatient services provided from 8/11/16 through 12/31/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The Level of Care Utilization System (LOCUS) is an accepted, national standard for determining the appropriate level of care for adults. During the dates of service in dispute, in terms of risk of harm, the records support a score of 2. There was no documentation of prior suicide attempts or current suicidal or homicidal ideation. The patient did have passive suicidal ideation. With regards to functional status, the records support a score of 3. The patient had moderate impairment. It appeared that the patient was unemployed. In terms of medical/addictive/psychiatric comorbidity, the records support a score of 3. The patient has no serious medical problems. However, he had been overusing alcohol. He reports having persistent depression since middle school. With regards to recovery environment, the records support a score of 2. The patient had a mildly stressful environment. He had pressure from his family regarding expectations to perform well in school. In terms of level of support, the records support a score of 2. The patients parents were supportive of the patient. With regards to treatment history, the records support a score of 2. It does not appear that the patient participated in extensive outpatient treatment prior to the intensive outpatient program admission. In terms of engagement and recovery status, the records support a score of 2. The patient was attentive and engaged during treatment. The patient appeared motivated for change and was compliant with medication. Therefore, the records support a composite score of 16.  Based on these criteria, the patient met criteria for routine outpatient services. The patient could have been treated through outpatient psychopharmacology and routine outpatient individual and group therapy. The patients alcohol use could have been treated through a sober living environment along with Alcoholics Anonymous groups. The patient continued to require treatment for his persistent depressive disorder and anxiety, but this could have been done in a less restrictive environment. Thus, mental health intensive outpatient services provided from 8/11/16 through 12/31/16 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.