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 one-on-one trauma therapy. 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. Applying the LOCUS framework, this patient meets the criteria for weekly one-on-one trauma therapy services. For dimension 1, the patient has been at moderate risk of harm (score 3) due to her history of suicide attempt at age 15. Following newfound sobriety, the patients  trauma symptoms were triggered, and without substances to help her cope with the trauma symptoms, she became suicidal and presenting to the emergency room. She was ambivalent about her protective factors, citing that her childrens father was taking care of them and voicing despair regarding her trauma symptoms. The patient denied suicidal intent or plan. She consistently continued to endorse safety and lack of suicidal ideation in the context of IOP and PHP treatment. No active suicidal ideation, but extreme distress and a history of suicidal behavior exists. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her inability to care for her children and or return to work, which demonstrates a deterioration in her ability to fulfill responsibilities. The patient cites conflict in her familial relationships, which triggers her trauma symptoms. This supports a significant deterioration in ability to fulfill responsibilities and obligations to job and significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has significant comorbidity (score 3) given her symptoms of depression, but even more debilitating are her symptoms of PTSD, which threaten her instability and safety. These symptoms were less apparent when the patient was actively using substances, but in maintaining her sobriety, the PTSD symptoms threaten her relapse. Significant psychiatric symptoms and signs are present which are themselves somewhat debilitating, and which interact with and have an adverse effect on the course and severity of any co-occurring substance use disorder. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The records document that the patient was raised by parents who used substances heavily and exposed her to violence and trauma throughout her childhood. The patient has been alienated from her family for the last few years and has struggled with these relationships, attempting to work through her anger towards her family though simultaneously struggling with re-triggered PTSD symptoms. There is a presence of ongoing or intermittent conflict, alienation, or other difficulties. For dimension 4B, the patients recovery environment provides limited support (score 3) as her childrens father providing support and taking care of the children for her, but the patient has no consistent family support. Very few actual or potential sources of support are available. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3). As the patient started working towards sustained sobriety from substances, she her mood and PTSD symptoms have become more acute. She has benefited from highly structured supportive interventions but requires continued strong professional support to maintain stability. At least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings. For dimension 6, the patient has shown positive engagement and recovery (score 2) given her ability to maintain sobriety for eight months. In addition, she has become progressively more motivated to work on her comorbid psychiatric issues of PTSD and major depressive disorder. The patient has a positive attitude toward treatment and has been help-seeking though acknowledging her own role in recovery. The patient is willing to change and is actively working toward it. These findings give the patient a composite score of 19, which is consistent with high intensity community-based services. For patients meeting this level of care criteria, treatment needs require multiple contacts weekly with intensive support and treatment. Considering this patients trauma symptoms, triggering past suicidality and leading to her destabilization, individual and group therapy with trauma-informed providers is recommended. For these reasons, the requested weekly individual trauma-informed psychotherapy services are 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.