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) behavioral health level of care adult treatment. 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.For dimension 1, the patient has been at moderate risk of harm (score 3) due to her history of fluctuating passive suicidal ideation with thoughts to overdose. She has a history of overdose in 2019. No active suicidal/homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior exists. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) since she has been unable to work due to her anxiety. Moreover, the patient endorses obsessive thinking including superstitious fears and worries that occupy up to three hours per day. This supports significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has minor comorbidities (score 2) including hypothyroid and increased use of alcohol. The 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 mildly stressful (score 2). The records document that the patients daughter recently moved out and her ex-husband is still involved in her life through her daughter. There is presence of some ongoing or intermittent interpersonal conflict, alienation, or other difficulties. For dimension 4B, the patients recovery environment is supportive (score 2) as she has an outpatient psychiatrist and therapist, but only sees them on a monthly basis. Supportive resources are not abundant but are capable of and willing to provide significant aid in times of need. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3). The patient was stable until the past several weeks when her ex-husband contacted her daughter. She has a history of setbacks with involuntary inpatient hospitalizations for suicidal ideation. She remains at high risk of decompensation in a lower level of care. At least partial recovery has been maintained for moderate periods of time, but only with strong professional support or peer support or in structured settings. For dimension 6, the patient has shown positive engagement and recovery (score 2). The records document that she has been adherent with treatment. The patient has a positive attitude toward recovery and treatment, capable of developing trusting relationships, and uses available resources independently when necessary. This gives the patient a composite score of 18, which is consistent with high intensity community-based services, such as IOP. Per LOCUS, IOP services are expected to last three months. Given these findings, the patient meets the six LOCUS dimensions to support an indication for the requested IOP services. Thus, the requested IOP behavioral health level of care adult treatment is 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.