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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center level of care. 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. For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. The submitted documentation includes a recent suicide risk assessment that concluded that the patient was at moderate risk. This qualifies the patient for moderate risk of harm in this dimension. [Score 3  Moderate Risk of Harm].For dimension 2  Function. This dimension measures the degree to which a person is able to fulfill social responsibilities, interacts with others, maintains their physical functioning, as well as a persons capacity for self-care. Records indicate that the patient has not been able to succeed in school or hold down a job. The patient has not been able to demonstrate the ability to adequately overcome eating disorder thoughts and behaviors to eat and drink adequately. The patient continues to have intrusive thoughts and ruminations about eating along with severe depressive symptoms. The patient can only walk by using a walker, and she suffers from multiple medical issues related to eating disorders. This qualifies the patient for serious impairment in this dimension. [Score 4  Serious Impairment]For dimension 3  Comorbidity. This dimension measures potential complications in the course of illness due to the level of acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient has multiple medical complications, depression and anxiety in addition to anorexia. This qualifies for significant comorbidity in this dimension. [Score 3  Significant Co-Morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patients mother suffers from alcoholism and appears to be unable to provide meaningful help. This qualifies as a highly stressful environment. [Score 4  Highly Stressful Environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patients reported social history includes little support, with the patients mother noted to suffer from alcoholism. The patients mother, aunt and sister were otherwise noted to be supportive. This qualifies as limited support in the environment for this dimension. [Score 3 Limited Support in Environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient has a history of very poor responses to multiple programs. This qualifies for poor response to treatment and recovery management for this dimension. [Score 4  Poor Response to Treatment and Recovery Management]For dimension 6  Engagement. This dimension assesses a patients understanding of their illness and treatment, and their ability and willingness to engage in the treatment and recovery process. Records reflect that the patient has gained some weight with a BMI of over 19, but she continues to have severe eating disorder signs and symptoms. Based on this, the patient qualifies for limited engagement and recovery in this dimension. [Score 3  Limited Engagement and Recovery]These findings give the patient a composite LOCUS score of 24, which is consistent with Level 5: Medically Monitored Residential Services. The patients score of 4 in the Functional Status dimension also automatically qualifies her for Level 5. This level of care has the capacity to treat persons who are suffering from long term and persistent disabilities that require extended rehabilitation and skill building.The patients scores under the six LOCUS dimensions take into account the specific needs of the patient for the purpose of treating their illness and its symptoms. The LOCUS framework for determining the appropriate level of care for adults needing mental health treatment is consistent with generally accepted standards of mental health, and it provides determinations that are clinically appropriate in terms of type, frequency, extent, site, and duration. The LOCUS dimensions are also free from consideration of 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. Accordingly, the Residential Treatment Center level of care services at issue and requested services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue and requested services were, and are, as defined in Health and Safety Code section 1374.72(a)(3)(A). 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.