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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for residential treatment center (RTC) level of care provided 9/01/21 through 10/04/21. Findings:  The physician reviewer found that 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 RTC services provided from 9/01/21 through 10/04/21. With regard to risk of harm, the records support a score of 3. The patient has had SI without intent or conscious plan and without past history of suicide.In terms of function, the records support a score of 3. The patient quit her job, was unable to work, and has caused serious conflict at home. The patient has not been sleeping and needs prompting for ADLs.With regard to comorbidity, the records support a score of 3. The patient is on hormone replacement therapy, which may contribute to her mood presentation. The patient is also overweight, which potentially can cause medical conditions.In terms of level of stress of the recovery environment, the records support a score of 3. The patient has had serious discord in her family relationships at home, feeling that she cannot return back home after treatment, and recently leaving her job due to inability to meet the pressure to maintain that responsibility.With regard to level of support of the recovery environment, the records support a score of 4. The patient has limited social support and is on bad terms with her family. Therefore, she is unable to use those supports in a constructive manner.In terms of treatment and recovery history, the records support a score of 4. The patient has been in outpatient treatment for the last ten years, without remission of depressive symptoms.With regard to engagement, the records support a score of 4. The patient has great difficulty owning her own responsibility for recovery and fails to complete follow-up tasks from groups during treatment. The patient is also intrusive at times and requires staff redirection, but again, she has a hard time accepting responsibility for this and becomes angry.These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services or RTC. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. Moreover, the services at issue were 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, RTC level of care provided 9/01/21 through 10/04/21 was medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.