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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensive outpatient program (IOP) services, one-on-one in person, five days per week, for three hours per day for three weeks. 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 met the criteria for IOP services, in person, five days per week, for three hours per day, for three weeks. For dimension 1, the patient is at low risk of harm (score 2) due to no current suicidal ideation or homicidal ideation. However, the patient has reported intrusive thoughts of death and he has demonstrated severe distress. The records document no current suicidal or homicidal ideation, plan, intentions or severe distress, but the presence of transient or passive thoughts recently or in the past. For dimension 2, the patient has exhibited moderate functional impairment (score 3) since his  compulsions have occupied up to eight hours a day, he has been unable to fulfill responsibilities and obligations, and he is struggling to function. The patient has shown significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has minor comorbidities (score 2) considering the presence of minor medical problems, which are not currently affecting his presentation. There is existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. For dimension 4A, the patients recovery environment is mildly stressful (score 2) due to a mildly stressful environment as he attempts to function with his severe symptoms and performance pressure. The records document performance pressure (perceived or actual) in school or employment situations creating discomfort. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider noted that the patient relies heavily on his parents for support without much evidence of other support. A few supportive resources exist in the current environment and may be capable of providing some help if needed. For dimension 5, the patient has demonstrated poor response to treatment and recovery management (score 4) since the patient has been in outpatient treatment consistently for much of 2021 without much improvement in his symptoms. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient has shown limited engagement and recovery (score 3). The records document that the patient relates to treatment with some difficulty with trouble accepting responsibility for his own recovery. The patient has shown limited ability to accept responsibility for recovery. These findings give the patient a composite score of 19, which is consistent with high intensity community-based services or IOP. Additionally, the patients current treatment interventions have not included prolonged exposure and response prevention therapy, which is the gold standard in treatment of OCD and offered at the Gateway program, where the patient has been accepted for treatment. Moreover, the requested IOP services are 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, and not primarily for the convenience of the patient or provider. For these reasons, the requested IOP services, one-on-one in person, five days per week, for three hours per day for three weeks 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. 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.