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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for one-on-one weekly psychiatry visits, one-on-one weekly therapy visits, and/or Xanax 2 mg tablets, one tablet every six to eight hours. 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 for 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. For dimension 1, the patient has been at serious risk of harm (score 4) given her expression to providers that she is actively suicidal with plan to overdose on Visine eye drops, but she has been able to safety plan, though tenuously so. She presents as agitated and impulsive. Current suicidal and/or homicidal ideation with expressed intentions, with some expressed inability to aversion to doing so. For dimension 2, the patient has demonstrated serious functional impairment (score 4) due to significantly conflicted interactions in most treatment relationships with aggressive and impulsive statements and behaviors. The patient reports difficultly sleeping. The patient has been unable to work due to her level of dysfunction. Inability to perform close to usual standards in work and other obligations and these responsibilities may be completely neglected on a frequent basis or for an extended period of time. For dimension 3, the patient has major comorbidities (score 4) considering her inability to tolerate many medications attempted other than benzodiazepines. Medical conditions exist which are clearly made worse by the existence of the presenting disorder. For dimension 4A, the patients recovery environment has been mildly stressful (score 2). The provider noted that the patient continues to have ongoing interpersonal conflict. This supports the presence of some ongoing interpersonal conflict, alienation, or other difficulties. For dimension 4B, the patients recovery environment provides minimal support (score 4). The patients only support is her husband. The patient has substantial difficulty accessing support and creates interpersonal difficulties in most professional support relationships. Very few actual or potential sources of support are available. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4). The records document that the patient has tenuous therapeutic relationships, and she has not been able to maintain mood stability for any prolonged period of time. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 6, the patient has shown minimal engagement and recovery (score 4) given her great difficulty building an alliance with her providers and poor ability to relates to her treatment teams. The patient has not been able to accept any responsibility for her recovery, she relates poorly to treatment and treatment providers, and her ability to trust is extremely narrow. The patient also does not accept any responsibility for recovery or feels powerless to do so. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. Per LOCUS, the patients scores of 4 for risk of harm and functional status also support Level 5 medically monitored residence-based services level of care. The patient has requested one-on-one weekly psychiatry visits and one-on-one weekly therapy visits, which are also supported as medically necessary based on the LOCUS criteria. The patient also requested Xanax 2 mg every six to eight hours for anxiety. However, benzodiazepines are contraindicated in patients with PTSD and borderline personality disorder. Given these findings, the requested one-on-one weekly psychiatry visits and one-on-one weekly therapy visits are medically necessary for treatment of this patient, while the requested Xanax 2 mg every six to eight hours is not 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 partially 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.