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 therapy sessions once a week. 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 1. The patient has a low risk of harm, as she denies suicidal ideation and does not have a history of suicide attempts. In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment as the patient reports struggling at work, in her relationships, with self-care, and in her efforts to support her child. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of psychiatric diagnoses, migraine headaches, and likely peri-menopausal status. 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 her childs significant mental health issues, including suicidal ideation, and concerns about ensuring a safe home environment for her child. The patient reported work-related stressors, and did not have contact with her sister due to a falling out several years prior. With regard to level of support of the recovery environment, the records support a score of 2 as the patient had supportive friends and family. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, as she failed to maintain remission of symptoms or optimal control with prior treatment that included outpatient individual and group therapy, an IOP, and medication trials. With regard to treatment acceptance and engagement, the records support a score of 2. The patient is positively engaged in treatment and utilizes multiple coping skills. Thus, the patient has a total score of 16. In this case, the recommended level of care is low intensity community-based services. In this patients case, individual therapy sessions once a week are 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, individual therapy sessions once a week 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.