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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and for psychotherapy services and prospective authorization and coverage for unlimited 90-minute psychotherapy office visits. 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 composite score is then used to determine the level of care needed. Applying the LOCUS guideline, this patient meets the criteria for the psychotherapy services provided, as well as future unlimited 90-minute psychotherapy office visits. The patient has been at serious risk of harm (score 4) as evidenced by chronic impulsive behavior, suicidal threats, self-harm, and inability to adequately care for herself. The patient has demonstrated severe functional impairment (score 4) with recurrent extreme deterioration in social interactions and her refusal to eat or care for herself with neglect of personal hygiene. The patient has significant comorbidities (score 3) in terms of autism, PTSD, anxiety, and possible borderline personality disorder. The patients recovery environment is moderately stressful (score 3) due to discord with her sister, inability to hold job, and significant social isolation. The patients recovery environment provides limited support (score 3). The patient has exhibited moderate response to treatment (score 3) since she has not achieved complete remission of her symptoms and she would be unable to continue treatment as an outpatient without strong professional support. The patient has shown limited engagement (score 3) as she relates to treatment with some difficulty. The patient continues to experience significant mood instability, extremes of devaluation and idealization of the provider, and difficultly engaging in outside resources. This gives the patient a composite score of 23, consistent with medically monitored residence based services. However, due to the patients behavioral health issues, she has difficulty developing trust, yet she has built a rapport with her current provider. The patient has been dependable in attending outpatient psychotherapy with the same provider since July 2019. In addition, she LOCUS recommends that high intensity community based services are appropriate for patients who need intensive support and treatment, but who are living either independently or with minimal support in the community. For these reasons, the psychotherapy provided, as well as future unlimited 90-minute psychotherapy office visits, were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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.