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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly psychotherapy sessions. 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 psychotherapy. For dimension 1, the patient is at minimal risk of harm (score 1) due to consistent denial of suicidal ideation with no past suicide attempts. No indication of suicidal or homicidal thoughts or impulses, and no history of suicidal or homicidal ideation, and no indication of significant distress. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given his job loss during the pandemic and unhappiness with his current job, which he started in November 2020. The patient recently started experiencing panic attacks at work and he is struggling to function. Significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has no comorbidities (score 1). The records document no co-morbidity. No evidence of medical illness, substance use disorders, or psychiatric disturbances apart from the presenting disorder. For dimension 4A, the patients recovery environment is moderately stressful (score 3) considering his significant transitions in employment and his perception of pressure to perform that surpasses his ability to meet obligations. Perception that pressure to perform surpasses ability to meet obligations in a timely or adequate manner. For dimension 4B, the patients recovery environment provides limited support (score 3) since the patient lives with his boyfriend and roommate, but these supports have limited ability to participate in assisting patient. A few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3). The records document that the patient was previously in outpatient treatment with medication management and psychotherapy though without complete remission of symptoms and ambivalent attachment to therapist due to social anxiety. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has shown positive engagement and recovery (score 2) due to the patients motivation for treatment and seeking therapy to address his personal role in his symptoms. Willing to change and is actively working toward it. These findings give the patient a composite score of 16, which is consistent with low intensity community-based services such as weekly individual psychotherapy. For these reasons, the weekly individual psychotherapy services are medically necessary 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. 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.