Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with opioid use disorder, stimulant use disorder, insomnia disorder, social anxiety disorder, major depressive disorder, and generalized anxiety disorder. On 1/28/19, the patient was noted to be sabotaging his recovery with negative behaviors, as he presented a meeting card to his therapist that contained fake signatures. The patient reported that he did not get his meeting card signed as requested. On 1/29/19, the patient was noted to have signs of anxiety and depression but denied suicidal ideation. On 2/2/19, the patient was noted to be withdrawn and isolating. On 2/5/19, the patient was noted to be anxious and listless. His insight and judgment were noted to be poor. The patient was noted to be cooperative and attentive in his therapy session. On 2/8/19, the patient rated his anxiety and depression as one of five. On 2/12/19, the patient denied cravings and reported that he had obtained a sponsor. The patients judgment and insight into his problems continued to be poor. At issue in this case is whether IOP services that were provided from 1/27/19 through 2/14/19 were medically necessary for the treatment of the patients medical condition. In this case, the patient had poor judgment and limited insight into his need for treatment. The patient showed some commitment to therapy but also exhibited counterproductive behaviors including dishonesty. He continued to have symptoms of his mental illness, including depression, anxiety, and insomnia. The patient was noted to be at continued risk for substance use as well as relapse. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by behavioral health managers and clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm, the patients score is 2, due to recent suicidal ideation reported on 1/22/19, that appeared passive in nature. For functional status, the patient score is 2, due to problems with interpersonal interaction with staff and peers. For comorbidity, the patients score is 3, due to overall medical stability with mental health issues, including recent passive suicidal ideation on 1/22/19, and depression and anxiety that had an adverse effect on his substance use issues. For recovery environment level of stress, the patients score is 2, due to his stable living environment. For recovery environment level of support, the score is 2, due to the presence of supportive resources including the patient having a sponsor. For treatment and recovery history, the patients score is 3, due to a fair recent treatment response in the IOP, but with consideration of deceitful behaviors as well as continued depression and anxiety. For engagement and recovery status, the patients score is 3, due to fair cooperation in treatment but limited ability to accept responsibility for recovery. The patients composite LOCUS score is 17, which correlates with high intensity community-based services, consistent with the services provided at the IOP level of care. Therefore, IOP services that were provided from 1/27/19 through 2/14/19 were medically necessary for this patient.Final Result: The reviewer determined that the requested services 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 with subspecialty certification in child and adolescent 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.