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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) level of care. Findings:  The physician reviewer found that 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 moderate risk of harm, due to chronic difficulties with food intake, leading to her being underweight. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to inability to participate in school or relationships as a result of her symptoms. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to chronic medical conditions of PTSD and OCD that affect mental health.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 due to discord with her mother, and poor physical health. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has relied on her mother for support, but has challenges with the relationship. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, due to the persistence of her symptoms despite recent inpatient hospitalization, and treatment at the residential, partial hospital and intensive outpatient levels of care. With regard to treatment acceptance an engagement, the records support a score of 2. The patient shows positive engagement and recovery as she actively participated in treatment and was motivated to make changes, although progress was slow. Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored non-residential services. Therefore, IOP level of care was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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.