Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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 IOP services. For dimension 1, the patient was at moderate risk of harm (score 3) due to her recent history of self-harm and suicidal ideation, as well as aggression toward her boyfriend. The records support history of chronic impulsive suicidal behavior or threats, but current expressions do not represent significant change from usual behavior. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given her conflict with boyfriend, disturbed sleep, and difficulty fulfilling work responsibilities, with recent gains made in the structured context of IOP. Recent gains and/or stabilization in function have been achieved while participating in treatment in a structured and/or protected setting. For dimension 3, the patient has significant comorbidities (score 3) considering the patients recent substance use that adversely affected her mental health. The patient had recent substance use which has 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 was moderately stressful (score 3). The records document that the patient experienced conflict with her boyfriend and she was primarily reliant on him for support. There was significant discord with family and other important relationships. For dimension 4B, the patients recovery environment provided limited support (score 3) considering the patients reliance on her boyfriend for most of her support and the volatility of their relationship. The patient received limited support from her family. Usual sources of support may be somewhat ambivalent, alienated, difficult to access, or have a limited amount of resources they are willing or able to offer when needed.  For dimension 5, the patient exhibited moderate or equivocal response to treatment and recovery management (score 3). At least partial recovery was maintained for moderate periods of time, but only with strong professional or peer support or in structured setting. This was demonstrated by the patients improvement as well as her continued struggles in IOP. For dimension 6, the patient demonstrated positive engagement and recovery (score 2) due to her active participation in treatment and commitment to practicing the skills that she learned. She also took responsibility for her recovery. The patient showed recognition of personal role in recovery and accepts significant responsibility for it. These findings give the patient a composite score of 20, which is consistent with medically monitored non-residence based services. Per LOCUS, This level of care refers to services provided to patients capable of living in the community either in supportive or independent settings, but whose treatment needs require intensive management by a multidisciplinary treatment team. Services, which could be included in this level of care, have traditionally been described as partial hospital programs and as assertive community treatment programs. In this case, the IOP level of care is actually lower than the recommended level of care determined by the use of the LOCUS algorithm. Per LOCUS, minimal oversight should be required for this level of service and reviews should not be required more often than every two weeks for persons with acute conditions and every two months for those with more (slowly) evolving conditions. As this patient has a diagnosis of borderline personality disorder, her condition can be considered slowly evolving. Her entire course of IOP treatment lasted less than two months. For these reasons, the IOP services 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.