Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for three (3) to four (4) weeks of in-person Intensive Outpatient Program (IOP) services, three (3) to five (5) days per week, consisting of one (1) hour of group therapy, exposure response prevention (ERP) therapy, and additional cognitive-behavioral therapy (CBT).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 (Astressors, and B-supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. Unintentional harm may also result from a patients inability to adequately care for oneself. The patient has had transient suicidal thinking in response to the severity of her OCD but has no history of suicide attempts or suicidal intent or plan. [Score 2  low risk of harm]For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. The patient lives at home with her family. She has had significant social withdrawal due to the severity of her OCD. She is not working due to her OCD and she has had to drop some of her college classes as well. She has had significant problems with eating and sleeping due to her OCD. She has serious impairment as evidenced by an inability to perform close to usual standards in school, work, or other obligations and significant withdrawal and avoidance of almost all social interactions. [Score 4  serious impairment]For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patients primary condition is her OCD. She has comorbidities of IBS and amenorrhea. These constitute minor co-morbidities, however, as these medical problems are not themselves immediately threatening and they have no impact on the course of the presenting disorder. [Score 2- minor co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient has a mildly stressful environment, as she lives with her parents and twin brothers. There are conflicts at home related to the severity of her OCD and rituals and how these affect her family. There have been no significant losses or transitions noted. The patient meets criteria of having some ongoing interpersonal conflict or other difficulties. [Score 2  mildly stressful environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient's family is supportive of her getting treatment. The patient is currently receiving treatment from her psychiatrist and an outside therapist once weekly. She participated in a virtual IOP but did not find this helpful. The patient has limited support due to there being few supportive resources in her current environment that may be capable of providing some help if needed. [Score 3- limited support in environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient has been in treatment for her OCD for a few months but has not been able to access the specific therapy at the recommended intensity and frequency. She has not had a significant improvement in her ability to function as she had previously. She has had a poor response to treatment with her previous or current treatment not achieving optimal control of symptoms. [Score 4- poor response to treatment and recovery management]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient has been in treatment for her OCD, and she is attending scheduled appointments and engaged in treatment. She appears to have a positive attitude toward recovery and treatment. The patient also appears to be capable of developing trusting relationships, and she uses available resources independently. [Score 2- positive engagement and recovery]These findings give the patient a composite score of 19, which corresponds with Level 3, High Intensity Community Based Services. Level 3 is consistent with an Intensive Outpatient Program (IOP) level of care. Accordingly, the requested three (3) to four (4) weeks of in-person Intensive Outpatient Program (IOP) services, three (3) to five (5) days per week, consisting of one (1) hour of group therapy, exposure response prevention (ERP) therapy, and additional cognitive-behavioral therapy (CBT), are medically necessary for treatment of the patients medical condition, obsessive compulsive disorder (OCD).Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patient's 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.