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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 16 weeks of weekly in-person psychotherapy. 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 3. The patient has a significant risk of harm, due to endorsing passive suicidal ideation, without intent or plan, and without past suicide attempts, and describing being in extreme distress and frustration. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to having very few supports as a result of her mental health issues, leaving her with conflicted relationships. With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity due to a history of alcohol use disorder in remission. The records note that the patient has been prescribed benzodiazepines recently due to heightened distress, which may lead to a relapse given her history of alcohol use disorder. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient has a mildly stressful environment due to relationship stressors leaving her more socially isolated. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has conflicted relationships due to her mental health, including symptoms of anxiety and depression, limiting her ability to access support. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, as she has been in individual psychotherapy in the past with some gains, though unable to be maintain the gains for longer periods of time outside of that treatment. She has undergone TMS and multiple psychotropic trials without remission of symptoms. With regard to treatment acceptance and engagement, the records support a score of 3. The patient is motivated for therapy, although it seems that she has limited ability to accept responsibility for her recovery. Thus, the patient has a total score of 19. In this case, the recommended level of care is medically high intensity community-based services. In this patients case, 16 weeks of weekly in-person psychotherapy are 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, 16 weeks of weekly in-person psychotherapy 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.