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. 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, this patient met the criteria for a portion of the IOP services. For dimension 1, the patient has been at moderate risk of harm (score 3) due to no reports of suicidal ideation, although the patient is quite distressed. No active suicidal or homicidal ideation, but extreme distress exists. For dimension 2, the patient has demonstrated moderate functional impairment (score 2) given her difficulties with regard to interpersonal relationships and some difficulty in social role functioning and meeting her obligations. Recently conflicted, withdrawn, alienated or otherwise troubled in most significant relationships, but maintains control of any impulsive, aggressive or abusive behaviors. There are significant disturbances in physical functioning such as sleep, eating habits, activity level, but without a serious threat to health. For dimension 3, the patient has significant comorbidities (score 3) considering her positive urinalysis for morphine although the patient denies use. The patient may be in early abstinence from substance use, which likely has a significant impact on her depression, and she has only achieved this in the context of a structured treatment program. Recent substance use which has had clearly detrimental effects on the presenting disorder, but which has been temporarily arrested through use of a highly structured or protected setting or through external means. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The records document no significant stressors apart from some ongoing interpersonal struggles and rejections. Significant discord or difficulties in family or other important relationships or alienation from social interaction. Midway through this admission, the patient reported that she was doing well at work and in school, which supports a mildly stressful recovery environment (score 2). Presence of some ongoing or intermittent interpersonal conflict, alienation, or other difficulties. For dimension 4B, the patients recovery environment has been supportive (score 2) due to support from her mother. Supportive resources are not abundant but are capable of and willing to provide significant aid in times of need. For dimension 5, the patient has demonstrated significant response to treatment and recovery management (score 2). The patient demonstrated success in controlling most of her symptoms. Current experience in treatment has been successful in controlling most symptoms but intensive or repeated exposures may have been required. For dimension 6, the patient has shown positive engagement and recovery (score 2). The providers report that the patient has been well engaged in her current treatment regimen in IOP. She recognizes and understands her illness and demonstrates a desire for recovery. The patient shows recognition of personal role in recovery and accepts significant responsibility for it. These findings give the patient an initial composite score of 17, which is consistent with high intensity community-based services. However, the patients score was reduced to 16, which supports low intensity community-based services. Therefore, a portion of the IOP treatment center services was medically necessary for this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.