Appeal type: Medical Necessity
Decision: Upheld 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) 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 does not meet the criteria for IOP mental health services. For dimension 1, the patient has been at minimal risk of harm (score 1) since there is no documentation of suicidal or homicidal thoughts or impulses, and no history of suicidal or homicidal ideation, and no indication of significant distress. There is no documentation of suicidal ideation or self-injurious behavior over the past six years. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given his significant disturbances in physical functioning such as sleep, but without a serious threat to health. The patient is having disturbances in sleep and difficulty with interpersonal interactions, but his physical well-being is not threatened due to these issues. For dimension 3, the patient has minor comorbidities (score 2). He has a documented history of substance use, although the records state that he has been sober from substances and there is no documentation that substance use contributes to his current disorder. The patient may occasionally experience psychiatric symptoms which are related to stress, but these are transient. For dimension 4A, the patients recovery environment is moderately stressful (score 3) considering his recent breakup, resulting in interpersonal loss. This supports a significant transition causing disruption in life circumstances. For dimension 4B, the patients recovery environment is highly supportive (score 1). The records document that the patients mother is highly supportive and is advocating for services on his behalf, there is no note of lack of supportive resources. Plentiful sources of support with ample time and interest to provide for both material and emotional needs in most circumstances. For dimension 5, the patient has shown significant response to treatment and recovery management (score 2). The patients prior records documenting multiple admissions were from 2013 through 2014. This suggests that recovery has been managed for moderate periods of time with limited support or structure. For dimension 6, the patient has exhibited positive engagement and recovery (score 2). The patient has engaged in treatment as well as treatment planning, participating in groups, and attending the program without any noted difficulties. 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 14, which is consistent with low intensity community-based services. Per LOCUS, the patient does not meet the criteria for IOP services. Therefore, the IOP mental health services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.