Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage 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 meets the criteria for IOP services. For dimension 1, the patient is at moderate risk of harm (score 3) since he has experienced chronic struggles with suicidal ideation and he has a history of two suicide attempts along with substance use. Although the patient has been sober from drugs and alcohol for two years, he has active depressive and anxiety symptoms with intermittent suicidal ideation without a specific plan. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) due to his challenges with schoolwork and maintaining bonds with friends and family. The patients father has provided the patient with extra support. The patient has shown a significant deterioration in his ability to fulfill responsibilities and obligations to school and self. He has been unable to eat, complete homework assignments, or take his medications as prescribed. For dimension 3, the patient has significant comorbidities (score 3) considering his diagnosis of bipolar affective disorder. He has also exhibited significant anxiety and depression in the context of a history of substance abuse. Significant psychiatric symptoms and signs are present while are themselves somewhat debilitating, and which interact with and have an adverse affect on the course and severity of any co-occurring disorder. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The patient has not been able to meet demands for social reciprocity with friends and family. He reported challenges with completing school requirements and withdrew from school in the past semester. The patient has experienced alienation from social interaction. For dimension 4B, the patients recovery environment provides limited support (score 3) given his difficulties with living independently without significant concerns by friends and family. The patient has a few supportive resources who are capable of and willing to provide significant aid in times of need. For dimension 5, the patient has shown moderate or equivocal response to treatment (score 3) with ongoing difficulties despite multiple medication changes, ECT, individual therapy, and hospitalizations in the past. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has exhibited limited engagement and recovery (score 3). The records document that the patient has challenges with maintaining engagement and does not appear to be regularly meeting with his sponsor. The patient does not use available resources independently or only in cases of extreme need. These findings give the patient a composite score of 21, which is consistent with medically monitored community based services, such as IOP level of care. Accordingly, the IOP services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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.