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. Findings:  The physician reviewer found that 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. Applying the LOCUS framework, this patient meets the criteria for IOP services. For dimension 1, the patient has been at some risk of harm (score 2) given his mood lability and potential to relapse. He has not expressed current suicidal ideation. Past history of fleeting suicidal thoughts with no current ideation, plan, or intention and no significant distress. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) as he is not employed and has few, if any, close relationships. The provider noted that the patient is facing potential homelessness. Conflicted, withdrawn, or otherwise troubled relationships with peers, adults, and/or family, but without episodes of physical aggression. For dimension 3, the patient has minor comorbidities (score 2) due to few medical problems, but he has a history of substance misuse. Occasional, self-limited episodes of substance use are present that show no pattern of escalation, with no indication of adverse effect on functioning or the presenting condition. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The records document that the patient has tension with his family as a result of his psychosis and he is facing homelessness. This supports a disruption of family milieu. For dimension 4B, the patients recovery environment provides limited support (score 3) due to significant strife with his father as a result of his mental illness, and his mother is supportive. He does have an outpatient provider who has worked with him for over 10 years. Community resources only partially compensate for unmet material and emotional needs and the patient has limited or inconsistent access to network. For dimension 5, the patient has shown moderate or equivocal resiliency and response to treatment (score 3) since he has failed and previous treatment with an outpatient provider as evidenced by his multiple relapses. However, he experienced several months of sobriety after RTC earlier this year. He is currently on a long-acting injectable, which is a medication for patients who do not adhere to treatment. He has not achieved complete remission of symptoms. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has been incompletely engaged (score 3) in treatment. The provider noted that the patient is adherent with treatment, yet he requires a great deal of encouragement and support to connect with treatment resources. He relapsed on non-alcoholic beer while in an RTC and reports ongoing cravings for alcohol. Acknowledges existence of problem, but resists accepting even limited age-appropriate responsibility for development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 19, which is consistent with high-intensity community-based services. Therefore, the requested IOP services 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 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.