Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for individual psychotherapy once per week and admission to a dialectical behavioral therapy (DBT) program.At issue in this case is whether individual psychotherapy once per week and admission to a DBT program are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.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 met and exceeded the criteria for weekly individual psychotherapy and in fact, meets criteria for PHP level of care. With regard to risk of harm, the records support a score of 4. The patient continues to endorse SI without current intent or plan, recent self-injurious behavior, and history of suicide attempt. In terms of function, the records support a score of 3. The patient has had significant conflicted relationships in all spheres of his life, including in his treatment.With regard to comorbidity, the records support a score of 3. The patient has obstructive sleep apnea, which can limit which medications he can take and also can worsen depressive symptoms.In terms of level of stress of the recovery environment, the records support a score of 3. The patient is being evicted from his home, is attempting to buy a new one and reported significant discord in many of his relationships.With regard to level of support of the recovery environment, the records support a score of 3. The patient has few supportive resources with family in New Jersey with whom he has a conflicted relationship.In terms of treatment and recovery history, the records support a score of 3. The patients previous treatment has not resulted in complete remission of symptoms or optimal control of symptoms. With regard to engagement, the records support a score of 3. The patient has a great deal of difficulty engaging in treatment, declining all options and then presenting in crisis. He has limited ability to accept his responsibility in recovery.These findings give the patient a composite score of 22, which is consistent with medically monitored community based services or partial hospitalization program (PHP) services.  For these reasons, patient exceeds medical necessity for weekly individual psychotherapy and actually qualifies for PHP level of care. Additionally, the patient meets the criteria for borderline personality disorder, for which DBT is first-line treatment. In this patients case, individual psychotherapy once per week and admission to a dialectical behavioral therapy (DBT) program are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. Moreover, the requested services 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, individual psychotherapy once per week and admission to a DBT program are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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.