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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services for a minimum of 30 days and up to 90 days at a facility that specializes in paranoid schizophrenia with negative affect and bipolar disorder. 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 meets the criteria for RTC services for a minimum of 30 days up to 60 days at a facility that specializes in paranoid schizophrenia with negative affect and bipolar disorder.For dimension 1, the patient has been at serious risk of harm (score 4) due to reports of passive suicidal ideation and self-harm by cutting but without current intent for suicide. Additionally, over the past year, the patient has shown a pattern of excessive substance use resulting in loss of self-control and harmful behavior with limited ability to abstain from use except while in a treatment setting. The records support a recent pattern of excessive substance use resulting in loss of self-control and clearly harmful behaviors with no demonstrated ability to abstain from use. For dimension 2, the patient has demonstrated serious functional impairment (score 4). The records document that the patient is currently homeless and unemployed. There is evidence that the patient has been unable to perform close to usual standards of functioning or meet obligations. For dimension 3, the patient has major comorbidities (score 4) given the patients uncontrolled substance use, which occurs at a level that poses a serious threat to health if unchanged and a serious barrier to his recovery from his depression and psychosis. The patient repeatedly becomes floridly psychotic and depressed in the context of substance use and he has been unable to control his use outside of a treatment setting. For dimension 4A, the patients recovery environment is highly stressful (score 4). The records document that the patient is homeless due to his substance use. The patient was evicted from transitional housing, and he has been unable to meet his own physical needs. There is report of inability to meet needs for physical and/or material well-being. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider noted that the patients mother and aunt are supportive, but their resources to support the patient physically and emotionally have been exhausted. When engaged, the patients resources are able to assist and are supportive. The usual sources of support may have a limited resources they are able to offer when needed. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4) since the patients only recovery is attained in the context of highly structured settings like inpatient psychiatric units and the patient is unable to maintain those gains outside of intensive treatment. Attempts to maintain whatever gains that can be attained in intensive treatment have limited success, even for limited time periods or in structured settings. For dimension 6, the patient has shown minimal engagement and recovery (score 4). The records indicate that the patient avoids contact with and use of treatment resources if left to his own devices with difficulty accepting responsibility for recovery. The patient avoids contact with and use of treatment resources if left to own devices. These findings give the patient a composite score of 27, which is consistent with medically monitored residence-based services. Per LOCUS, the patients scores of 4 for risk of harm and functional status also support treatment at Level 5 medically monitored residence-based services. In addition, in terms of length of treatment, the patient meets the criteria for intermediate stay, level 5B, with expected length of stay not exceeding 60 days due to his ambivalence regarding his continued use of substances, which was only arrested while in a highly structured treatment setting. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, RTC services for a minimum of 30 days and up to 60 days at a facility that specializes in paranoid schizophrenia with negative affect and bipolar disorder are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.