Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 23-year-old female with major depressive disorder, generalized anxiety disorder, 
and cannabis use disorder. The patient has requested reimbursement for adult mental health 
residential treatment center services from 11/06/21 through 11/30/21. 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. Applying the LOCUS 
framework, the patient met the criteria for residential treatment services provided 11/06/21 
through 11/30/21. For dimension 1, risk of harm, the records support a score of 3. This dimension 
assesses potential for harm to self or others.  The patient was admitted for residential treatment 
with passive suicidal ideation, frequent self-injurious behavior and poor coping skills and history 
of self-aborted suicide attempt. For dimension 2, functional status, the records support a score 
of 4. This dimension assesses the degree to which a person is able to fulfill social responsibilities, 
interacts with, maintain physical functioning and capacity for self-care. The patient was unable 
to attend school or work due to severe symptoms. The patient was withdrawn socially from 
almost all social interactions. For dimension 3, comorbidity, the records support a score of 3. This 
dimension assesses potential complications in the course of treatment due to acuity or disability 
related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The 
patient has used cannabis daily prior to admission to the residential treatment center with 
significant negative impact on her psychiatric symptoms. For dimension 4A, level of stress of the 
recovery environment, the records support a score of 3. This dimension assesses the stressors in 
the environment, social circumstances, and interpersonal relationships. The patient had easy 
access to cannabis at home and had a recent break-up with her boyfriend of three years, causing 
increased stress. For dimension 4B, level of support of the recovery environment, the records 
support a score of 4. This dimension assesses the presence of family and social support to 
augment the recovery environment. The patient was isolated from friends, recently broke up 
with her boyfriend and isolated herself to her room much of the day, relying fully on her parents 
for support, although she had difficulty reaching out to even her parents. For dimension 5, 
treatment and recovery history, the records support a score of 4. This dimension assesses how 
past experiences with treatment and recovery might indicate how the patient might respond in 
the future. The patient was in outpatient treatment with inconsistent adherence to medications 
prior to residential treatment, but without optimal control of symptoms. For dimension 6, 
engagement, the records support a score of 3. This dimension assesses a patients understanding 
of her or her illness and treatment, and ability and willingness to engage in the treatment process. 
The patient appeared motivated in the residential treatment center, but had trouble engaging 
with some therapists and coped with stress in treatment with self-injury.  These findings give the 
patient a composite score of 24, which is consistent with medically monitored residence-based  services or residential treatment. Additionally, the patient scored a 4 in functional status, which 
supports residential treatment level of care. For these reasons, adult mental health residential 
treatment center services from 11/06/21 through 11/30/21 were medically necessary for the 
treatment of this patient.