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.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. With regard to risk of harm, the records support a score of 2. The patient has some potential for risk of harm, due to passive suicidal ideation and feelings of hopelessness.  In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to significant disturbance in the patients sleep, activity level, and concentration.With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of hypotension, coronary artery disease with history of open heart surgery, preoccupations with somatic complaints, and fear of COVID-19. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to being recently unemployed, searching for work unsuccessfully, and significant concerns about his physical health. With regard to level of support of the recovery environment, the records support a score of 3 as the patient appears to have limited support in his environment and limited ability to utilize any available social support. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, due to continued symptoms of depression and anxiety.With regard to treatment acceptance and engagement, the records support a score of 3. The patient has significant distrust of his treatment providers, and has trouble utilizing available resources independently. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. In this patients case, IOP level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, IOP services are medically necessary for the 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.