Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for eating disorder 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, the patient meets the criteria for eating disorder IOP services. For dimension 1, the patient has been at low risk of harm (score 2) given her intermittent expressions of passive suicidal ideation throughout treatment and during psychiatric follow-up appointments. The patient denies any current suicidal intentions or plan. No current suicidal or homicidal ideation, plan, intentions or severe distress, but the patient has had transient and passive thoughts recently or in the past. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) due to social isolation and withdrawal, with difficulty engaging socially in constructive activities. She has been distracted and anxious to the point of hitting a pedestrian with her car. The patient has made gains in treatment, but she has been unable to translate these gains outside of treatment. Ongoing severe deficits in interpersonal relationships, ability to engage in socially constructive activities, and ability to maintain responsibilities. For dimension 3, the patient has significant comorbidities (score 3) given her diagnosis of hypothyroidism, which complicates treatment of her eating disorder due to hypometabolism. Medical condition exists which may adversely affect the course of the presenting disorder. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) considering her recent alienation due to exposure to her mother who is COVID-19 positive and in the hospital. Significant discord or difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment has provided limited support (score 3). The records document that the patients main supportive resource, her mother, is now ill with COVID-19 and hospitalized. Due to this exposure and the patients eating disorder, she has been self-isolating. The patient has difficulty using supportive resources though only a few such resources exist for patient. A few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3) as she underwent prior treatment for her eating disorder and OCD without complete remission of symptoms. The patient has experienced difficulty maintaining any gains without strong professional or peer support in structured settings. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has shown limited engagement and recovery (score 3). The providers have noted throughout her treatment that she has been ambivalent regarding her treatment. The patient has limited ability to accept responsibility for recovery and demonstrates variability in acceptance of her illness and treatment plan. The patient has some variability, hesitation or uncertainty in acceptance or understanding of illness and disability. These findings give the patient a composite score of 20, which is consistent with medically monitored non-residence based services. Therefore, eating disorder 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.