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 three times a week consisting of individual therapy (90 minutes per day) and group therapy (90 minutes per day). 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. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due endorsement of passive suicidal ideation, becoming easily dysregulated, and an inability to cope with stressors. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to difficulty functioning daily. The records documented that the patient had called the crisis line several times over the last several months. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of migraine headaches, hypotension, and medication sensitivity. 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 a lack of social support and relying almost completely on the support of her treatment team. The records noted that a transition from the trauma program recently caused her to decompensate in her ability to function. With regard to level of support of the recovery environment, the records support a score of 3 as the patient is socially isolated and relies almost completely on her psychiatric treatment team for her support, destabilizing when she had to transition after over a year from the trauma program. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, having been treated at numerous levels of care with trouble stepping down between levels of care due to decompensating symptoms. The patient has a limited ability to hold onto gains made outside of structured programming. With regard to treatment acceptance and engagement, the records support a score of 3. The records noted that patient had was engaging and had become more trusting of her providers.  Thus, the patient has a total score of 22. In this case, the recommended level of care is medically monitored community-based services. In this patients case, IOP level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, IOP services three times a week consisting of individual therapy (90 minutes per day) and group therapy (90 minutes per day) are medically necessary for the 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 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.