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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for one to two months of residential treatment center (RTC) 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. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to current suicidal ideation and a history of suicidal behavior and chronic impulsive suicidal behavior and threats. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient appears to be engaging better with the treatment team and able to engage interpersonally in improved ways, although the patient is unable to function outside of a structured treatment setting at this time. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to numerous medical co-morbidities associated with the eating disorder, although these appear currently stable, and a possible diagnosis of autism spectrum disorder, complicating the treatment. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to being alienated from social interactions and the recent death of a grandfather, which added more stress. With regard to level of support of the recovery environment, the records support a score of 4 as the patient lives with three roommates but has alienated from all potential social supports. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment due to numerous hospitalizations, residential admissions, PHP, and IOP. The patient has started to improve by engaging more with the treatment team though this partial recovery is only maintained with strong professional support in structured settings.   With regard to treatment acceptance and engagement, the records support a score of 3. The patient was completely disengaged while in an RTC but then attained some improvement and stability upon readmission to an RTC. Overall, the patient continues to have limited ability to accept responsibility for own recovery. Thus, the patient has a total score of 23. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm noted, the patient meets LOCUS 5b extended stay criteria. In this patients case, RTC level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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, one to two months of RTC are medically necessary for the treatment of this patient. 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.