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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for partial hospitalization program services.At issue in this case is whether a partial hospitalization program 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 3. The patient repeatedly endorses suicidal ideation and homicidal ideation, although without clear plan, or intent.In terms of function, the records support a score of 3. The patient has had difficulty functioning at work, with numerous interpersonal difficulties in the work environment. She is not currently able to work and has trouble even engaging in virtual intensive outpatient program as she is so easily overwhelmed and triggered.With regard to comorbidity, the records support a score of 4. The patient struggles with chronic pain, which is both exacerbated by her psychiatric symptoms but also worsens her psychiatric presentation and makes her symptoms more difficult to treat. This chronic pain also elevates the patients suicide risk.In terms of level of stress of the recovery environment, the records support a score of 2. There is not much detail in the records regarding patients environmental stress other than the transitions and stress that she has  been enduring in her work environment.With regard to level of support of the recovery environment, the records support a score of 3. The patient has limited support in her environment, causing her stressors now to be even more debilitating without significant social support.In terms of treatment and recovery history, the records support a score of 3. The patient completed the partial program in the past with great improvement in her symptoms, although this remission was not able to be sustained.With regard to engagement, the records support a score of 3. The patient has trouble relating to treatment and building therapeutic alliances due to symptom triggers and trouble engaging in group format.These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services. In this patients case, partial hospitalization program is 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, the requested partial hospitalization program services are medically necessary for the treatment of the patients medical condition.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.