Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for individual psychotherapy services (as needed, referring one to two times per week, at a minimum). 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 meets the criteria for individual psychotherapy one to two times weekly at a minimum, although she would better be served by a higher level of care such as residential treatment center (RTC) services.For dimension 1, the patient has been at low risk of harm (score 2). The records document that the patient has no history of suicide attempts, but she endorsed passive suicidal ideation without intent or plan during her recent evaluation. The patient has no current suicidal or homicidal ideation, plan, intentions or severe distress, but may have had transient or passive thoughts recently or in the past. For dimension 2, the patient has demonstrated serious functional impairment (score 4) since the patient has become completely homebound since March 2020, preoccupied with her medical conditions, and she states that she is unable to leave her home due to physical fragility. The patient depends entirely on her mother and is unable to work or attend school. The records support significant withdrawal and avoidance of almost all social interaction as well as inability to perform close to usual standards in school, work, or other obligations and these responsibilities may be completely neglected on a frequent basis or for an extended period of time. For dimension 3, the patient has major comorbidities (score 4) due to her eating disorder and medical conditions that require medical monitoring such as chronic respiratory failure and vascular insufficiency. The patient indicated that she has not left her home since 2020, due to her medical conditions, which has prevented adequate medical and psychiatric treatment. There is documentation that medical conditions exist which may require intensive, although not constant, medical monitoring. For dimension 4A, the patients recovery environment is moderately stressful (score 3) given the patients preoccupation with her sustained decline in health, although is unwilling to be evaluated in person by her providers. The patient has expressed concern related to her decline in health status. For dimension 4B, the patients recovery environment provides minimal support (score 4). The records document that the patient is completely isolated at home and is relies on her mother as her only support. There are very few actual or potential sources of support available. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4) since the patient has been in inpatient level of care several times without remission of  symptoms. The records indicate that previous or current treatment has not achieved a complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient has shown minimal engagement and recovery (score 4) due to her limited ability to accept responsibility for her recovery and she is completely preoccupied with her medical symptoms. The patient does not accept any responsibility for recovery or feels powerless to do so. These findings give the patient a composite score of 25, which is consistent with medically monitored residence based services or RTC. In addition, the patients score of 4 for functional status supports treatment with medically monitored residence based services or RTC. In terms of length of stay, the patient meets criteria for level 5C or moderate intensity long-term RTC programs due to her chronic medical conditions, which are seriously exacerbated by concurrent psychiatric problems that are not adequately controlled outside of a structured setting. For these reasons, the patient requires psychiatric services, and RTC level of care is recommended due to her serious difficulties with functioning. If the patient is unwilling to accept this level of care, then the requested individual psychotherapy at least one to two times per week are medically necessary to her to help engage patient and motivate her to accept the more appropriate higher level of care. Moreover, the requested psychiatric services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the requested individual psychotherapy services (as needed, referring one to two times per week, at a minimum) are medically necessary for treatment of this patient. 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.