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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for medication management appointments once every two weeks through 2024 and/or one hour per week of one-to-one dialectical behavior therapy (DBT). 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, the patient meets the criteria for weekly individual DBT and biweekly psychopharmacology appointments. For dimension 1, the patient is at moderate risk of harm (score 3) due to intermittent impulsive suicidal ideation with a past history of suicidal ideation and numerous suicide attempts. The records document no active suicidal ideation, but extreme distress and a history of suicidal behavior exists. For dimension 2, the patient has demonstrated moderate functional impairment (score 3). The provider noted that the patient describes not functioning when her trauma symptoms are heightened. Over the last year, while in consistent treatment with psychiatry and individual therapy, the patient has been slightly more stable. When her trauma symptoms are worse, patient describes worsened hygiene, paranoia, and difficulty in relationships. There is evidence that recent gains and stabilization in function have been achieved while participating in treatment in a structured setting. For dimension 3, the patient has minor comorbidities (score 2) given her maintenance of sobriety from substances for two years, although this had previously exacerbated the patients symptoms. The patient has chronic pain, headaches, and gastrointestinal issues. The records support the existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. For dimension 4A, the patients recovery environment is mildly stressful (score 2) given her financial stressors with trouble paying her rent. The patient is able to work intermittently for food delivery services. The patients circumstances are causing some distress such as concern about maintaining material well-being. For dimension 4B, the patients recovery environment is supportive (score 2). The records document that although supportive resources are not abundant, the patient is able to access support from her partner and best friend when needed. Supportive resources are not abundant but are capable of and willing to provide significant aid in times of need. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3). The provider noted that the patient has struggled for many years with some improvement in her mood and trauma symptoms, although this partial recovery has been maintained only with continued support from providers. At least partial recovery has been maintained for periods of time, but only with strong professional support. For dimension 6, the patient has shown positive engagement and recovery (score 2). The records indicate that the patient is attached to her previous treatment team of the last year with some hesitation in attaching to her new team, but she is willing to change and actively working towards better mental health. The patient has a positive attitude toward recovery and treatment, capable of developing trusting relationships, and uses available resources independently when necessary. These findings give the patient a composite score of 17, which is consistent with high intensity community based services, which allows for treatment services three days per week, for up to two to three hours per day. Given this support, medication management appointments every two weeks and one hour per week of one-to-one DBT are medically necessary for treatment of this patient through 2022. However, the records do not support the medical necessity of the requested services through 2024. The medical necessity of additional services should be later determined based on the patients progress throughout 2022. Moreover, the requested services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the requested medication management appointments once every two weeks and one hour per week of one-to-one DBT are medically necessary for treatment of this patient.  Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.