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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for individual biweekly sessions of exposure and response prevention (ERP) therapy, or in the alternative, individual sessions once a week of ERP therapy. 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 meets the criteria for individual biweekly sessions of ERP therapy. For dimension 1, the patient is at low risk of harm (score 2) due to some recent suicidal ideation without plan, and no history of self-harm or suicide attempt. There is no current suicidal or homicidal ideation, intentions or severe distress, but may have had transient or passive thoughts recently or in the past. For dimension 2, the patient demonstrates moderate functional impairment (score 2) given the significant time she spends engaging in mentally exhausting OCD ruminations. The patient has been experiencing difficulties concentrating on school and her job due to obsessions and compulsions. There is significant deterioration in ability to fulfill responsibilities and obligations to job and self, and these may be avoided or neglected on some occasions. For dimension 3, the patient has minor comorbidities (score 3) considering her feelings of helplessness and suicidal ideation consistent with concomitant depressive symptoms. This supports 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 moderately stressful (score 3). The records document that the patient lives with her parents. She was previously attending college and she needs to deal with some challenging roommate dynamics. There is a significant transition causing disruption in life circumstances such as job loss, legal difficulties or change of residence. For dimension 4B, the patients recovery environment is supportive (score 2) due to her parents acceptance of the patient moving back home when she experienced issues while away at college. Supportive resources are not abundant but are capable of and willing to provide significant aid in times of need. For dimension 5, the patient exhibits moderate or equivocal response to treatment and recovery management (score 3). The patient has participated in outpatient therapy and multiple medication trials with limited success. Previous or current experience in treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has shown limited engagement and recovery (score 3) since she has been frequently dissatisfied by her caregivers and fixates on whether certain providers have sufficient expertise for her care. The patient relates to treatment with some difficulty and establishes few, if any, trusting relationships. These findings give the patient a composite score of 18, which is consistent with high intensity community based services. With regard to ERP as a treatment modality for OCD, researchers noted that cognitive behavior therapy (CBT) for OCD in youth involves four primary components: psycho-education, cognitive training, mapping of OCD, and exposure with response prevention. The meta-analysis of 13 studies performed  demonstrated significant reductions in Yale-Brown Obsessive-Compulsive scores with cognitive therapy that includes exposure with response prevention. Researchers noted that, Over the past several decades, considerable research has accumulated to show that ERP is an efficacious intervention for OCD. The method of delivery is important with in vivo therapist-assisted ERP, in conjunction with imagery, producing the greatest change in symptom severity. In this patients case, the provider is actively assessing the patients avoidance responses and other prevailing emotional states to tailor treatment to the patients needs. For these reasons, the requested individual biweekly sessions of ERP therapy are medically necessary for 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.