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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Weekly therapy that includes eye movement desensitization and reprocessing (EMDR), dialectical behavior therapy (DBT), and cognitive behavior therapy (CBT). 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 the requested weekly therapy services with EMDR, DBT and CBT modalities.For dimension 1, the patient has been at low risk of harm (score 2) due to lack of suicidal or homicidal ideation, but he has used alcohol and cannabis to manage his emotional state though without any significant episodes of potentially harmful behaviors. The records document occasional substance use without significant episodes of potentially harmful behaviors. For dimension 2, the patient has demonstrated mild functional impairment (score 2) given his interpersonal difficulties and feelings of detachment from others. The patient has been able to use therapy for some improvement in his functioning even despite periods of difficulty. The patient has been developing minor but consistent difficulties in social role functioning and meeting obligations such as difficulty fulfilling parental responsibilities or performing at expected level in work but maintaining ability to continue in those roles. For dimension 3, the patient has minor co-morbidities (score 2) considering his use of cannabis and alcohol to manage more difficult emotional states and stress, but this is self-limited and without escalation. The patient has shown occasional episodes of substance misuse, but any recent episodes are self-limited, show no pattern of escalation, and there is no indication that they adversely affect the course of a co-occurring psychiatric disorder. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The records document that the patient has experienced relationship stressors with his two daughters, whom he is parenting alone since his ex-wife died several years ago. The patient also moved during the last year as well. There is report of significant discord or difficulties in family and alienation from social interaction. For dimension 4B, the patients recovery environment provides limited support (score 3) due to the patients isolation from most social relationships, feeling detached from others, and with few supports. Usual sources of support may be somewhat ambivalent, alienated, difficult to access or have a limited amount of resources they are willing or able to offer when needed. For dimension 5, the patient has shown moderate or equivocal response to treatment and recovery management (score 3) since the patient has been in therapy for a couple of years with significant gains though with difficulty maintaining those gains without continued strong professional support. At least partial recovery has been maintained for moderate periods of time, but only with strong professional support. For dimension 6, the patient has exhibited positive engagement and recovery (score 2). The provider noted that the patient has been motivated and engaged in therapy. The patient was recently started on an antidepressant, and he has expressed increasing recognition of his role in his recovery. The patient has shown recognition of personal role in recovery and accepting significant responsibility for it. These findings give the patient a composite score of 17, which is consistent with high intensity community based services, which would allow for treatment services three days per week, up to two to three hours per day. For these reasons, weekly individual psychotherapy is medically necessary for this patient. As for the modalities requested, the patient carries diagnoses of post-traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). Based on standard practice and the below treatment guidelines, CBT has been shown to be effective for the treatment of patients with PTSD and GAD. Additionally, as per the current guidelines and reviews, both EMDR and DBT are effective and indicated for this patient with a diagnosis of PTSD, and DBT is also supported for patients with GAD. Moreover, the requested services 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 not primarily for the convenience of the patient or provider. Therefore, the requested weekly therapy that includes EMDR, DBT and CBT is medically necessary for 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.