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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential treatment at a facility that specializes in obsessive compulsive disorders. Findings:  The physician reviewer found that based upon review of the submitted documentation there is a lack of support for the requested services in this clinical setting. The letter from the treating provider indicates that her current recommendation is intensive outpatient treatment. Additionally, the records indicate that this patient has had successful treatment of his OCD symptoms with individual and group psychotherapy in the recent past.  The record does not indicate any reason as to why the patient would not be able to benefit from or participate in an intensive outpatient OCD treatment program as recommended by his treating provider. The records do not indicate any dangerous behaviors for issues with self-harm that would preclude the patient from participating in intensive outpatient programming. Moreover, the evidence based literature regarding treatment of OCD indicates that medication management combined with outpatient psychotherapy is effective treatment. Studies found that Augmentation of SRI pharmacotherapy with exposure and ritual prevention is an effective strategy for reducing OCD symptoms. Studies noted Clomipramine, exposure and ritual prevention, and their combination are all efficacious treatments for OCD. In cases such as this, an evidence based, objective, instrument such as the Level of Care Utilization System (LOCUS) is useful in determining the necessary psychiatric level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. According to the LOCUS system, this patient had a score of two, which is a low risk of harm due to a lack of current active suicidal ideation with any plans. His functional status is determined as moderate with a score of three due to a significant inability to fulfill responsibilities and obligations. With regard to medical, addictive and psychiatric comorbidity, his score is one due to lack of substance abuse issues. The level of stress as well as his level of support in his recovery environment are scored as moderate, with a score of three due to his relational issues with family and few supportive resources. His treatment and recovery history is scored as two because the records show he has had good treatment response in the recent past.  His engagement and recovery status is also positive due to his cooperation in treatment and insight into need for treatment. The patients score in this section is between a two and three. The total score for this patient with regards to the level of care is a composite score between 16 to 17. A score of between 17 to 19 correlates with a treatment intensity level of three, which is high intensity community based services. According to the LOCUS system of scoring, this patient does not require residential treatment for his OCD behavior with a score of 16 to 17. In sum, the requested residential treatment at a facility that specializes in OCD is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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.