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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 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. Based on assessment with the LOCUS criteria, patient does not meet criteria for RTC services. For dimension 1, the patient is at moderate risk of harm (score 3) given his history of passive suicidal ideation without active urges or intent. He also has a history of self-injurious behavior. His passive suicidal ideation has been chronic and there are no new safety concerns. This supports a history of chronic impulsive suicidal/homicidal behavior or threats, but current expressions do not represent significant change from usual behavior. For dimension 2, the patient has demonstrated mild functional impairment (score 3) since he is currently attending college with support. Developing minor but consistent difficulties in social role functioning and meeting obligations such as difficulty fulfilling performing at expected level in school. For dimension 3, the patient has minor comorbidities (score 2) including Tourettes disorder, OCD, anxiety and ADHD. His parents report that he experiences mood lability in response to environmental stressors and demonstrates poor frustration tolerance, but he calms with time and reassurance. The records document the existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. For dimension 4A, the patients recovery environment is mildly stressful (score 2). The patient reports that he lives with his parents who are supportive and never leave him alone. There is presence of some intermittent personal conflict or other difficulties. For dimension 4B, the patients recovery environment is supportive (score 2) given his parents continued support and ongoing care and support from several providers with whom he has a good rapport. He is currently on Luvox, Klonopin, trazodone, and Lexapro. Professional supports are available and effectively engaged. For dimension 5, the patient has exhibited significant response to treatment and recovery management (score 2) since he has been in outpatient care with chronic mood lability but does stabilize with the support and validation of his providers. Previous or current experience in treatment has been successful in controlling most symptoms but intensive or repeated exposures may have been required. For dimension 6, the patient has a positive attitude toward recovery and treatment (score 2), capable of developing trusting relationships, and uses available resources independently when necessary. He has been under the care of a psychiatrist as well as a psychologist in the outpatient setting. Although the patient insists on RTC level of care, this is likely a symptom of his OCD. These findings give the patient a composite score of 16, which is consistent with low intensity community-based services. Therefore, the requested RTC services are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.