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

Findings:  The physician reviewer found that 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 3. The patient has a significant risk of harm, due to passive suicidal ideation, without current intent or plan, and without history of suicide attempts. In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to struggles functioning in work and at home, with minor disruptions in usual activities.With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity due to the presence of hypertension and severe sleep apnea, which may aggravate and worsen symptoms of depression and anxiety course with numerous downstream health effects to the patients current mood. 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 the patient's childrens mental health issues requiring the patient to watch them around-the-clock to ensure their safety.  With regard to level of support of the recovery environment, the records support a score of 2 as the patient is able to access support from wife and from a support group.  In terms of resiliency and treatment history, the records support a score of 2. The patient has significant resilience and/or response to treatment as, with adequate treatment, the patient's recovery has been managed for moderate periods of time with limited support or structure.With regard to treatment acceptance and engagement, the records support a score of 2. The patient is engaged and motivated when given the appropriate access to treatment.  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.