Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a three-week length of stay at a residential treatment center (RTC) and RTC treatments of a) somatic experiencing; b) sensorimotor psychotherapy; and/or c) eye movement desensitization and reprocessing (EMDR).  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 RTC services. For dimension 1, the patient is at serious risk of harm (score 4) due to expression of suicidal ideation, with a plan to shoot herself. The patients suicidal ideation was triggered by heightened PTSD symptoms, which continue to impair her ability to function. Current suicidal ideation with expressed intentions and a past history of carrying out such behavior but without means for carrying out the behavior, or with some expressed inability or aversion to doing so. For dimension 2, the patient has shown significant impairment (score 4) given her significant isolation, few social supports, and low level of functioning. The patient indicated that she is on leave from work due to her mental health issues. Significant withdrawal and avoidance of almost all social interaction. For dimension 3, the patient has significant comorbidities (score 3). The records document asthma and allergies as well as numerous recent somatic issues related to medications. The patient required treatment in the emergency department for medication adverse effect of myoclonus versus extrapyramidal symptoms. After coming off selective serotonin reuptake inhibitor (SSRI) medication, the patient experienced prolonged nausea and vomiting as well as neurologic symptoms, which complicates ongoing treatment. Medical conditions exist which may adversely affect the course of the presenting disorder. For dimension 4A, the patients recovery environment is moderately stressful (score 3) considering her limited social support, living with roommates. The patient has been unable to function at work, and she is isolative and withdrawn socially outside of her treatment. Significant discord or difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment provides limited support (score 4). The patients family lives in another state and they are limited in their ability to provide support. The patient is estranged from her mother. Her uncle is able to be a supportive point of contact but with difficulty meeting the patients emotional needs. Very few actual or potential sources of support are available. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4) due to cycling between levels of care since the start of 2020 with little improvement in her symptoms. The patient is unable to work or function due to the severity of her PTSD symptoms despite repeated attempts at treatment and multiple PHP admissions in the last year. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 6, the patient has shown minimal engagement and recovery (score 4) as she has switched treatment providers numerous times over the last year and she has experienced difficulty engaging in appropriate treatment. On discharge from RTC, the provider noted that the patient was unable to engage in treatment milieu. The patient states that she needs treatment to be focused on her trauma symptoms. Related poorly to treatment and treatment providers and ability to trust is extremely narrow. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. Per LOCUS, the patients scores of 4 for risk of harm and functional status also support medically monitored residence-based services level of care. Specifically, the patient meets criteria for Level 5B: Moderate Intensity Intermediate Stay Residential Treatment Program, with treatment up to 60 days based on the patient having suicidal ideation that is passive currently at relatively low risk for self-harm at present, and due to the patient demonstrating serious impairment in her ability to function at work and with unsuccessful previous treatment at lower levels of care. Therefore, the requested three-week length of stay at a residential treatment center is medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A). The requested three-week length of stay at a residential treatment center is in accordance with the generally accepted standards of medical health and substance use disorder care. Additionally, the requested three-week length of stay at a residential treatment center is clinically appropriate in terms of type, frequency, extent, site and duration. The requested three-week length of stay at a residential treatment center is not primarily for the economic benefit of the health care service plan and subscribers of for the convenience of the patient, treating physician or other health care provider. Given patients diagnosis of complex PTSD, the requested RTC treatments of a) somatic experiencing; b) sensorimotor psychotherapy; and/or c) eye movement desensitization and reprocessing (EMDR) are medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety code section 1374(a)(3)(A).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.