Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the intensive outpatient program (IOP) services for eating disorder 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. With regard to risk of harm, the records support a score of 3. The patient has a moderate risk of harm, due to the presence of severe symptoms of anorexia nervosa, as the patient's weight consistently fell below 85% of ideal body weight. In terms of functional status, the records support a score of 3. The documentation noted limited social support due to her mothers past struggles with her own eating disorder. The patient interacted with few friends and was deferring college admission. Her gains from treatment diminished with lower level of care. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity due to reported depression, amenorrhea that was treated with supplemental estrogen and, and an electrocardiogram demonstrating sinus bradycardia with marked sinus arrhythmia. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient moved back to her parents home for additional support, which was limited due her mothers past eating disorder. She had few friends and had deferred college entrance. With regard to level of support of the recovery environment, the records support a score of 3 as the patient had limited support from her parents and relied heavily on support from the IOP. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment, with symptomatology persisting despite treatment attempts at various levels of care and gains made only with strong professional support in structured settings. With regard to treatment acceptance and engagement, the records support a score of 2. The patient exhibited positive engagement and was invested in treatment with a positive attitude toward recovery but with struggles in adherence. Thus, the patient had a total score of 18. In this case, the recommended level of care was high intensity community-based services or IOP. Therefore, all of the IOP services for eating disorder treatment were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.