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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for partial hospitalization program (PHP) or 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 passive suicidal ideation without intent, a history of past suicide attempts, and chronic inability to tolerate frustration or ability to self-soothe effectively. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to struggles with continuing to work as she was only able to maintain gains in the context of an ongoing supportive and highly structured program. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity as she recently had a cholecystectomy and is still recovering from surgery with some complications. 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 isolation from her family and fears of failing. With regard to level of support of the recovery environment, the records support a score of 4 as the patient has a distanced relationship from her family and a tenuous ability to obtain support from her roommates and friends. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management due to being a high utilizer of medical and psychiatric services in the past year with little ability to maintain gains outside of an intensive, structured settings.With regard to treatment acceptance and engagement, the records support a score of 4. The patient was noted to be ambivalent regarding treatment, not accepting her role in recovery and avoiding contact with treatment resources until she was at a crisis point. Thus, the patient has a total score of 25. In this case, the recommended level of care is medically monitored residence-based services. 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, RTC services 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.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.