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 individual therapy sessions. Findings:  The physician reviewer found that 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 moderate risk of harm, due to recent suicidal ideation with thoughts of crashing her car but was able to plan for safety. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to continued severe symptoms of depression and anxiety along with suicidal ideation resulting in an emergency department visit the month prior. With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity due to the presence of dysmenorrhea. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient has a minimally stressful environment as her family is supportive, and her living environment poses no current threat.With regard to level of support of the recovery environment, the records support a score of 2 due to a supportive environment with individuals that are capable and willing to help provide support. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment due to a lack of significant improvement despite medication trials and some individual therapy. With regard to treatment acceptance and engagement, the records support a score of 2. The patient is motivated and working toward recovery. Thus, the patient has a total score of 17. In this case, the recommended level of care is high intensity community-based services. In this patients case, weekly individual therapy sessions 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, weekly individual therapy sessions 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.