Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for weekly individual therapy appointments once a week (one hour in length).At issue in this case is whether weekly individual therapy appointments once a week (one hour in length) are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.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 met the criteria for weekly individual psychotherapy. With regard to risk of harm, the records support a score of 2. Although the patient does not endorse any suicidal ideation, she has demonstrated trouble caring for herself, which has worsened since being laid off from her job, finding herself in bed most of the day.In terms of function, the records support a score of 3. The patient was laid off from her job and has continued to have trouble functioning since then. The patient continues to neglect her physical health, gaining weight and worsening the control of her diabetes.With regard to comorbidity, the records support a score of 3. The patient has insulin-dependent diabetes mellitus, which is poorly controlled, given her difficulty in caring for herself due to her symptoms of depression and anxiety.In terms of level of stress of the recovery environment, the records support a score of 3. The patient recently lost her job and is struggling financially.With regard to level of support of the recovery environment, the records support a score of 3. The patient lives alone and has very limited support in her environment.In terms of treatment and recovery history, the records support a score of 3. The patient has been in treatment with her current providers for the last 15 years, vacillating through levels of care, but with lack of remission of symptoms and continued significant mood and affective instability. The patient does better in a structured, regular therapeutic engagement of at least weekly individual therapy. She did much better when in IOP.With regard to engagement, the records support a score of 2. The patient is engaged and motivated for treatment despite self-terminating medication.These findings give the patient a composite score of 19, which is consistent with high intensity community-based services. Weekly individual psychotherapy one hour in length is medically necessary for treatment of this patient at the very least, if not a higher level of care, such as IOP.  In this patients case, weekly individual therapy appointments once a week (one hour in length) are 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, weekly individual therapy appointments once a week (one hour in length) are medically necessary for treatment of the patients medical condition.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.