Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services provided by Center for Discovery. 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 demonstrating self-neglect and trouble with self-care.In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to trouble functioning at work, missing deadlines, and poor hygiene. With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity due to the presence of memory loss.In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has a highly stressful environment due to repeated abuse from her autistic son, who lives with her, perpetually triggering the patients trauma symptoms.  With regard to level of support of the recovery environment, the records support a score of 3 as the patients support system appears to be lacking, and patient has trouble accessing any further social supports. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, given a 35-year history of outpatient treatment without an ability to maintain significant recovery.With regard to treatment acceptance and engagement, the records support a score of 3. The records note that the patient has memory issues and rigid ways of thinking, making it difficult to change, coupled with low self-esteem, limiting engagement. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. In this patients case, IOP level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and 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, IOP services provided by Center for Discovery were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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.