Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 45-year-old male who was admitted voluntarily on 8/02/19 for anxiety, depression, and binge type alcohol use. The patient has requested reimbursement for residential treatment from 8/02/19 through 9/13/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that 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. In terms of risk of harm, the records support a score of 3. This patient had a one-day period of binge drinking a few days before presenting to the facility for admission.  His last day of drinking had been three months prior. He had a history of transient suicidal ideation when intoxicated and was not suicidal throughout his admission. With regard to functional status, the records support a score of 3. He had been involved in extramarital affair with a client and was having significant discord with his wife as a result. He was still working, but had occasional episodes of neglecting parenting responsibilities.  There were no significant neurovegetative symptoms, and he was diagnosed with an adjustment disorder at the facility.  In terms of medical, addictive, and psychiatric comorbidity, the records support a score of 3. Due to significant comorbidity due to his binge drinking of alcohol. With regard to level of stress of the recovery environment, the records support a score of 3. He has had conflicts with his wife due to her discovering the extramarital affair. He lived in the family home with his children. He and his wife were in counselling to reconcile. In terms of level of support of the recovery environment, the records support a score of 2. He had an outpatient therapist. He has support from his wife, his family and the community.  With regard to treatment and recovery history, the records support a score of 3. The patient had an equivocal response to treatment and recovery management.
In terms of engagement and recovery status, the records support a score of 1. The patient had optimal engagement and recovery. He was willing to be in treatment and had understanding and acceptance of illness and its effect on function. Thus, the patient has a composite score of 18. This score indicates that high-intensity community-based services were medically necessary. Services which would be included in this level of care are described as intensive outpatient programs. Therefore, residential treatment from 8/02/19 through 9/13/19 was not medically necessary for the treatment of this patient.