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

The patient has requested authorization and coverage for intensive outpatient program (IOP) services, three (3) days a week comprised of three (3) DBT group therapy sessions a week, one cognitive behavioral therapy (CBT) group therapy session a week, one seeking safety group therapy session (for trauma, self-harm, and substance abuse) a week, one recovery skills group therapy session (for substance abuse) a week, one one-hour individual DBT session a week, and 10 minutes of DBT telephone advice per week. The progress notes indicate that the patient recently completed two separate IOP programs. A discharge summary from the most recent IOP indicates the patient struggled with cannabis use as well as regulation of emotions and behavioral issues. Recent clinical evaluations recommended a third trial of IOP treatment. The most recent discharge progress notes indicate that the patient had engaged in self-harm in February 2019 yet she reported that she was not experiencing any active suicidal ideation. Applying the Level of Care Utilization System (LOCUS) from the American Association of Community Psychiatrists, this patient meets the criteria for IOP services. 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. The records indicate that this patient is at moderate risk of harm (score 3) due to a lack of current suicidal ideation with a history of passive suicidal ideation recent self-harm. The patients functional status is mildly impaired (score 2) due to some interpersonal issues and minor disruptions in activities of daily living. The patient has minor comorbidities (score 2) given her overall medical stability with substance abuse issues that include cannabis use without possible evidence of adverse effects on psychiatric conditions. The patients recovery environment is mildly stressful (score 2) as she has a stable living environment and her recovery environment is supportive (score 2). The patient has demonstrated fair treatment response in the previous IOP that she completed yet continues to struggle with applying her skills (score 3). Further, the patient has been positive and engaged in her treatment (score 3) with good cooperation and participation but hesitation in accepting understanding of her illness and some continued behavioral issues. This gives the patients presentation a composite score. This score correlates with a treatment intensity level of three, which is consistent with high intensity community based services, such as IOP level of care. Accordingly, IOP services, three (3) days a week comprised of three (3) DBT group therapy sessions a week, one CBT group therapy session a week, one seeking safety group therapy session (for trauma, self-harm, and substance abuse) a week, one recovery skills group therapy session (for substance abuse) a week, one one-hour individual DBT session a week, and 10 minutes of DBT telephone advice per week is supported as medically necessary for treatment of this patients behavioral health issues. 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 with subspecialty certification in child and adolescent 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.