Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensive outpatient program (IOP) level of care services. Findings:  The physician reviewer found that 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 3. The patient has a significant risk of harm, due to a high-risk score on the Columbia Suicide Severity Rating Scale (CSSRS) and a recent history of self-harm and a suicide attempt. In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment as the patient reported problems in her interpersonal interactions due to irritability and conflict. With regard to comorbidity, the records support a score of 1. The patient did not have comorbidities.In terms of level of stress of the recovery environment, the records support a score of 2.  The patient has a mildly stressful environment due to intermittent interpersonal conflict. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has limited support due to interpersonal conflict. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment due to a six-year history of mood lability and treatment with psychiatry since age ten, though her current response to treatment is unclear with little effort or motivation on her part to connect with treatment. With regard to treatment acceptance and engagement, the records support a score of 4. The patient has challenges engaging in treatment with limited follow through on treatment recommendations. Thus, the patient has a total score of 18. In this case, the recommended level of care is high intensity community-based services. In this patients case, IOP level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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 services are medically necessary for the 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.