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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for two in-person counseling sessions per week. For dimension 1, the patient has been at low risk of harm (score 2). The patient uses a substance as documented in the records and has recently experienced a great deal of distress. Occasional substance use without significant episodes of potentially harmful behaviors. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) due to the patients continued struggles throughout the pandemic with worsening symptoms and reduced ability to function, heightened anxiety to the point of patient not being able to function or utilize medical resources. Significant disturbances in physical functioning such as sleep, eating habits, activity level, or sexual appetite, but without a serious threat to health. For dimension 3, the patient has minor comorbidities (score 2) given their long history of autism and more recently substance use disorder. Additionally, the patient is preoccupied with medical issues, which are not substantiated in the records. The patient may occasionally experience psychiatric symptoms which are related to stress, medical illness, or substance use, but these are transient in nature and have no detectable impact on a co-existing substance use disorder. For dimension 4A, the patients recovery environment has been mildly stressful (score 2) given the chronic stress in their environment in the last year due to the pandemic, which has been especially troublesome to the patient given their diagnosis of autism and their need for consistency. The patient may also have substance use disorder, which should be further explored. For dimension 4B, the patients recovery environment provides limited support (score 3). The records document that the patient has few social supports, although these supports are able to help advocate for the patient and provide support. A few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3) considering the patients difficulties with effort and motivation on previous therapy assignments. The patient has not demonstrated significant improvement in symptoms with weekly individual therapy. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has shown limited engagement and recovery (score 3) given the patients limited engagement with treatment, multiple requests for changes in provider, not showing for visits, and trouble accepting responsibility for their recovery. The patient relates to treatment with some difficulty and establishes few, if any, trusting relationships. The patient has limited ability to accept responsibility for recovery. These findings give the patient a composite score of 18, which is consistent with high intensity community based services. The requested twice weekly in-person psychotherapy services 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 not for the convenience of the patient or provider. Therefore, the requested two in-person counseling sessions 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.