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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient treatment services and Intensive Outpatient (IOP) services.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- Risk of Harm. This dimension assesses potential for harm to self or others. At the time of admission to inpatient treatment, the patient showed significant emotional dysregulation and clear elevation of chronic suicidal behavior and threats. These behaviors reflect that the patient was at serious risk of harm. [Score 4  Serious Risk of Harm]For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with, maintain physical functioning and capacity for self-care. Records indicate that the patient had deficits in her ability to fulfill obligations and engage in socially constructive activities, and deficits in her ability to maintain responsibilities. These deficits and limitations correspond with moderate impairment in functional status. [Score 3  Moderate Impairment]For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. Records indicate that the patient had used marijuana to self-medicate, but there was no indication that her use was uncontrolled or that it had an adverse effect on the course of her psychiatric disorders. [Score 2  Minor Co-Morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. Notes indicate that the patient had significant stressors related to a stressful employment situation and that she felt overwhelmed and unable to meet her employment obligations. [Score 3  Moderately Stressful Environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the recovery environment. Records reflect that the patient had family support and support from her boyfriend, and they were capable and willing to participate in treatment. [Score 2  Supportive Environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The record indicates the patient had been engaged in treatment in the past, but she had not achieved a stable recovery or good control of her symptoms. [Score 3  Moderate or Equivocal Response to Treatment and Recovery Management]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and ability and willingness to engage in the treatment process. The record indicates that the patient was well engaged in her treatment. She recognized and understood her illness, she demonstrated a desire for recovery, and she was taking an active role in her recovery process. [Score 2  Positive Engagement and Recovery]Thus, the patient has a composite score of 19 for the period of inpatient treatment. While this composite score corresponds with a Level 3: High Intensity Community Based Services level of care, the patient had a score of 4 for her Risk of Harm, and this score constitutes independent criteria that would require admission to Level Five: Medically Monitored Residence-Based Services, regardless of the patients composite score. Accordingly, the inpatient treatment services at issue were medically necessary to treat the patients condition.Regarding the later period of services at issue, during which the patient received Intensive Outpatient (IOP) services, the patients composite score would be 16. The patients scores during this period would be changed for three dimensions. The patients score for dimension 1 (Risk of Harm) would be 3 (Moderate Risk of Harm), as the patients thoughts of self-harm were no longer present, and providers indicated that her risk for such behavior was low. The patients score for dimension 4A (Recovery Environment - Stress) would be 2 (Mildly Stressful Environment), as records reflect that perceived stressors related to the patients employment situation created discomfort. The patients score for dimension 5 (Treatment and Recovery History) would be 2 (Significant Response to Treatment and Recovery Management), as the patients previous experience in treatment had been successful in controlling most symptoms, but intensive or repeated exposures may have been required. The composite score of 16 for the later period of services at issue is consistent with Level 2 (Low Intensity Community Based Services). Accordingly, the Intensive Outpatient (IOP) services at issue were not medically necessary to treat the patients condition.Final Result: The reviewer determined that one of the two services at issue was medically necessary to treat the patients condition. Therefore, the Health Plans denial should be partially 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.