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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensive outpatient program (IOP) services three times per week. 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, the patient met the criteria for IOP services. For dimension 1, the patient is at moderate risk of harm (score 3) due to reports of passive suicidal ideation. The provider noted that the patient is quite dysregulated though without any intent or conscious plan and no past suicide attempts. The records support significant current suicidal ideation without intent or conscious plan and without past history. For dimension 2, the patient is demonstrating moderate functional impairment (score 3) considering her difficulties in her internship, increased isolation, and trouble maintaining control over impulsive and dysregulated behaviors. The patients recent gains have only been the context of the structured program. The patient has shown ongoing and/or variably severe deficits in interpersonal relationships, ability to engage in socially constructive activities, and ability to maintain responsibilities. For dimension 3, the patient has significant comorbidities (score 3) given her debilitating migraines during times of stress. The patient recently presented to the emergency department with a migraine and increased debilitation. Medical conditions exist which may have been created or adversely affected by the existence of the presenting disorder. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The provider noted that the patient lives alone and only receives support from her treatment providers. The patient reported that transitioning to a new treatment program is a source of stress. The patient has significant discord and difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment provides minimal support (score 4) since the patient lives alone and has few sources of support outside of her psychiatric treatment. Overall, the records indicate that 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). Per the providers, the patient started to make some progress in the trauma program, but only after about one year of intensive treatment and only in the structured setting of that program. The records document that at least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support and in a structured setting. For dimension 6, the patient has shown limited engagement and recovery (score 3) due to difficulty establishing trusting relationships with treatment providers and then becoming overly dependent on those providers. The patient relates to treatment with some difficulty and establishes, few, if any, trusting relationships. These findings give the patient a composite score of 22, which is consistent with medically monitored community-based services. Thus, the patient meets the LOCUS criteria for IOP services. Moreover, the requested IOP services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. Given these findings, the requested IOP services three times per week 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.