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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for weekly individual therapy.At issue in this case is whether weekly individual therapy is medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.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 denied any suicidal ideation that was current, or any history of suicidal ideation, homicidal ideation, or extreme vulnerability.In terms of function, the records support a score of 1. The patient continues to work long hours, but appears to be having no trouble on their job as a correctional officer apart from feeling stressed by the hours. There are no complaints with sleep or appetite and they report no interpersonal problems. Record does not indicate any deterioration of function.With regard to comorbidity, the records support a score of 1. The patient presents with some distress related to their work situation. There are no substance use issues or physical health problems that exacerbate this situation.In terms of level of stress of the recovery environment, the records support a score of 2. The patient appears to have significant stressors related to a new job situation and the long hours required. This causes some discomfort around their perceived ability to perform adequately.With regard to level of support of the recovery environment, the records support a score of 2. There is minimal information regarding the patients support systems in the record. It is reported that the patient lives with their family and that they feel that they have good support, although there is no indication that there are abundant sources of support.In terms of treatment and recovery history, the records support a score of 2. The record provides little information about past treatment, but they were seeing a therapist in the past and wishes to resume treatment with the same person. The patient considered the treatment to be helpful.With regard to engagement, the records support a score of 1. The record indicates that the patient was well engaged in present treatment and would like to resume previous treatment. The patient recognizes and understands the source of their distress and demonstrates a desire to learn how to process it better.These findings give the patient a composite score of 10, which is consistent with basic services (Level 0). The patient was offered services consistent with this level. For these reasons, weekly individual therapy is not medically necessary for treatment of this patient. Weekly individual therapy is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, weekly individual therapy is not clinically appropriate in terms of type, frequency, extent, site, and duration. Weekly individual therapy is 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, weekly individual therapy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.