Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services provided by Central Coast Treatment Center. 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 1. The patient had a low risk of harm, as the records did not document suicidal ideation and the patient was able to care for herself.  In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to anxiety and her preoccupation with controlling her eating, causing her to avoid any occasion in which food might be a component.  With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to amenorrhea and bradycardia secondary to the eating disorder, along with intermittent stomach pain and vomiting.  In terms of level of stress of the recovery environment, the records support a score of 3.  The patient had a moderately stressful environment due to stress from school, placing pressure on herself, conflictual relationships with her parents, and a break-up with her boyfriend.With regard to level of support of the recovery environment, the records support a score of 3 as the patient had few supportive resources, distancing herself from her parents, competing with her sister, and breaking up with her boyfriend. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment, as she had a history of treatment with partial recovery maintained only with strong professional support and in structured settings. With regard to treatment acceptance and engagement, the records support a score of 2. The patient was motivated for treatment and recognized her own role in recovery. Thus, the patient has a total score of 17. In this case, the recommended level of care was high intensity community-based services. In this patients case, IOP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, IOP level of care was medically necessary for the 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.