Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for anger management treatment. 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 Level 3 high intensity community-based services. However, there is a lack of support in the medical literature for anger management treatment. For dimension 1, the patient is at moderate risk of harm (score 3) due to previous suicide attempt and a history of self-harm behaviors. The records document that the patient has denied any suicidal or homicidal ideation. However, the patients noted in her appeal documentation that she struggles with suicidal ideation. The records document no active suicidal ideation, but extreme distress and a history of suicidal behavior exists. For dimension 2, the patient has mild functional impairment (score 2). The records document that the patient is employed and has a roommate. The patient has been able to advocate for herself. The patient requested treatment in an anger management group, which suggests that she struggles to manage her anger. The patient has been experiencing some problems in interpersonal interactions, with increased irritability, hostility or conflict, but is able to maintain some meaningful and satisfying relationships. For dimension 3, the patient has minor comorbidities (score 2) considering her psychiatric diagnoses of major depressive disorder, post-traumatic stress disorder (PTSD), and borderline personality disorder, as well as co-occurring obesity and asthma. There are 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) since the records document work-related and personal stressors, but details regarding those stressors are sparse. This supports performance pressure in employment situations creating discomfort. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider noted that the patient is only partially utilizing available supports. Thus, the patients resources are only partially utilized even when available. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3). Prior treatment has included outpatient therapy, psychiatric care, several psychotropic medication trials, inpatient psychiatric hospitalization following a suicide attempt several years ago. Previous or current treatment has not achieved complete remission or optimal control of symptoms. For dimension 6, the patient has shown limited engagement and recovery (score 3) since the patient has struggled to establish trusting relationships with treatment providers and has declined some treatment services. The records support that the patient relates to treatment with some difficulty and establishes few, if any trusting relationships. Per the LOCUS, these findings give the patient a composite score of 18, which is consistent with Level 3 high intensity community-based services. Per the American Psychological Association guidelines, the recommended treatment of depression in the general adult population includes psychotherapy and antidepressant pharmacotherapy. General models of psychotherapy which appear to have comparable effects for the treatment of depression include dialectical behavior therapy (DBT), cognitive, cognitive-behavioral therapy (CBT), and mindfulness-based cognitive-therapy, interpersonal psychotherapy, psychodynamic therapies, and supportive therapies. In particular, DBT and CBT are well-established interventions and have demonstrated efficacy and effectiveness for patients with borderline personality disorder. The evidence does not support anger management therapy for the treatment of the patients depression, borderline personality disorder, or PTSD. Moreover, the requested anger management therapy is not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the requested anger management treatment is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.