Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for psychiatric 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. Applying the LOCUS guideline, this patient did not meet the criteria for psychiatric IOP treatment services. The patient was at low risk of harm (score 2) as she has a history of passive suicidal ideation, but she was free of suicidal ideation since October 2019, after starting treatment with TMS. She has history of a suicide attempt at age 19 that she described as attention seeking. She had occasional substance use without significant episodes of potentially harmful behaviors. The patient demonstrated mild functional impairment (score 2) as she was on leave from work for several months due to her mental health issues. The patient does not have any reported medical comorbidities (score 2). The patient does have a history of daily cannabis use up until the day for admission with occasional cocaine use on weekends. She was able to refrain from use of substances throughout the duration of the IOP admission except for one isolated incident of cannabis use. The patients recovery environment involved a low level of stress as she lives in a shared apartment with a friend (score 1). This living environment appears to be low stress and does not pose a risk to the patients recovery. The patients recovery environment was supportive as she had an outpatient psychiatrist and therapist (score 2). She was willing to engage in 12 step groups in the community. She has demonstrated partial response to treatment (score 3) but she has not achieved complete remission of symptoms or optimal control of her symptoms. The patient was enthusiastic about recovery (score 1). The provider described the patient as trusting, and noted that the patient appeared to be taking on a personal role and responsibility in a recovery plan. This gives the patient a composite score of 15, which is consistent with low intensity community based services. Per LOCUS, programs of this type are traditionally clinic-based with treatment programming ranging from three hours per week to one hour every two weeks. Given these findings, the psychiatric IOP treatment services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine 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.