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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for weekly in-person cognitive behavioral therapy (CBT) for one year and/or prescription management appointments once every two weeks for one year, or in the alternative for a shorter duration. 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, the patient meets the criteria for a higher level of care. For dimension 1, the patient has been at moderate risk of harm (score 3) due to a history of a suicide attempt by overdose and repeatedly endorsements of passive suicidal ideation without intent or plan on evaluations. The records document no active suicidal ideation, but extreme distress and a history of suicidal behavior exists. For dimension 2, the patient has shown moderate functional impairment (score 3). The patient has been unable to work since quitting a job in November 2020 due to anxiety symptoms and has continued to struggle to function. The patient also has a history of conflicted relationships. For dimension 3, the patient has significant co-morbidity (score 3) having required care in the emergency department and urgent care in the last few months for symptoms of chest tightness, anxiety, gastroesophageal reflux disease (GERD), dizziness, and nausea. The patient is severely obese, which places a higher risk for medical complications. Medical conditions exist which may adversely affect the course of the presenting disorder. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) considering the patients issues with the partner. The patient indicated that the partner has been physically abusive. The patient has also been struggling with a roommate and the patient has expressed concerns about becoming homeless. The records document significant discord or difficulties in family and other important relationships. For dimension 4B, the patients recovery environment provides limited support (score 3) due to conflicted relationships and limited support. The patient reports continuing to manage to care for their two children during allotted parenting time. The patient has limited constructive involvement with any professional sources of support that are available. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4). The provider noted that the patient has never been hospitalized psychiatrically and has been seen by psychiatry every three to four months. Most recently, the patient completed twice weekly DBT group but struggled to function throughout entire course of treatment. Previous or current treatment has not achieved complete remission of symptoms or optima control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient has shown limited engagement and recovery (score 3) due to some variability, hesitation, and uncertainty in accepting or understanding of illness and disability. The patient has not been forthcoming about which medications are being taking, but does present as constantly in crisis. These findings give the patient a composite score of 22, which is consistent with medically monitored community based services. Consistent with the medical literature, the patients diagnoses and symptoms support weekly CBT and medication management every two to four weeks for at least one year. In addition, the requested weekly in-person CBT for one year and prescription management appointments once every two weeks for one year are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for the convenience of the patient or provider. All told, the requested weekly in-person CBT for one year and prescription management appointments once every two weeks for one year are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.