Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services.At issue is whether intensive outpatient program (IOP) services provided from 1/01/21 forward to treat the patients mental health or substance use disorder were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).California Health and Safety Code section 1374.72(a)(3)(A) states that 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.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. Although the patient has no homicidal ideation, she has frequent passive suicidal ideation with worsened anxiety. Additionally, she has persistent difficulty in her ability to care for herself despite some gains made in the first month of receiving IOP services. This qualifies the patient for moderate risk of harm in this dimension. [Score 3  Moderate Risk of Harm]For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with, maintain physical functioning and capacity for self-care. When the patient initially presented to receive IOP services, she had significant impairment in her personal hygiene and self-care. The patient made improvements during the month that she received IOP services, but these gains have only been maintained while participating in treatment in this structured setting, and she immediately destabilized again upon removal of this structured setting. This qualifies the patient for moderate impairment in this dimension. [Score 3  Moderate 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 patient has irritable bowel syndrome, chronic pain, and insomnia. These conditions are not immediately threatening and they have little impact on the patients current presenting disorder. This qualifies for minor comorbidity in this dimension. [Score 2  Minor Comorbidity] For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patient lives in an assisted living facility that has recently been on lockdown due to COVID-19. This qualifies, at the very least, as a mildly stressful environment. [Score 2  Mildly Stressful Environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the recovery environment. The patients recovery environment is limited due to the current pandemic and the patients social isolation. The patient is able to access help from her supports, if needed, though they have incomplete ability to participate in treatment and in supporting the patient due to the pandemic. This qualifies for limited support in the environment for this dimension.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 struggled significantly during the past year, with psychiatric hospitalization and 30 rounds of ECT required to stabilize the patient earlier in the year, though without establishing full recovery. Additionally, while the patient was able to make gains during the month that she received IOP services, these gains are only maintained with strong professional support in structured settings like an IOP setting. Immediately, on termination of IOP services, the patient regressed with worsening symptoms. This qualifies for moderate or equivocal response to treatment and recovery management for this dimension. For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and ability and willingness to engage in the treatment process. The patient has had difficulty accepting responsibility for recovery. During her therapy sessions, the patient repeatedly perseverated in a catastrophizing way without demonstrating the ability to modulate these symptoms yet using cognitive behavioral therapy (CBT) skills. The patient also had numerous technological issues that prevented her from fully participating in the sessions. Based on this, the patient qualifies for limited engagement and recovery in this dimension. [Score 3  Limited Engagement and Recovery]Thus, the patient has a composite score of 19, which corresponds with a Level 3: High Intensity Community Based Services level of care, or IOP. The patients scores under the six LOCUS dimensions take into account the specific needs of the patient for the purpose of treating her illness and its symptoms. The LOCUS framework for determining the appropriate level of care for adults needing mental health treatment is consistent with generally accepted standards of mental health, and it provides determinations that are clinically appropriate in terms of type, frequency, extent, site, and duration. The LOCUS dimensions are also free from consideration of 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. Accordingly, the requested intensive outpatient program (IOP) services were, and are, medically necessary.The reviewer determined that the requested intensive outpatient program (IOP) services were, and are, medically necessary.