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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 14 days 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. Applying the LOCUS framework, the patient meets the criteria for 14 days of RTC services. For dimension 1, the patient is at serious risk of harm (score 4) due to impulsivity and suicidality, whether gestures or with true intent, that have escalated over the last month. The patient has repeatedly endorsed suicidal ideation. The patient was treated in the emergency department after an intentional overdose. This supports current suicidal ideation with expressed intentions and past history of carrying out such behavior but without means for carrying out the behavior, or with some expressed inability or aversion to doing so. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her unstable level of functioning based on her significant mood and affective instability. Most recently, the patient presented with worsened depression and anxiety as well as difficulty fulfilling home responsibilities. The records document significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has significant comorbidities (score 3) considering her multiple medical problems, including Raynauds. The provider noted that Abilify caused tremors and the patient remains somatically focused. Thus, medical conditions exist which may require significant medical monitoring. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The records document that the patient has experienced significant discord in her marriage. The patient has exhibited recent decompensation and suicidal gesture in attempting to elicit an emotional response from her husband. These findings support serious disruption of family and social milieu due to severe conflict. For dimension 4B, the patients recovery environment provides minimal support (score 4) since the patients only supports are her health care providers and her husband. The patients relationship with her husband is unstable, and the patient reportedly committed a suicidal gesture to elicit emotion from him. The usual supportive resources display little motivation or willingness to offer assistance, or they are themselves troubled or hostile toward the patient. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4). The provider noted that the patient has been in treatment with her current providers for the last 15 years. The patient has been treated at various levels of care, but with lack of remission of symptoms and continued significant mood and affective instability. This supports that previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient has demonstrated minimal engagement and recovery (score 4). The patient is needy of her health care providers, seeking them out in crisis constantly, but she has no ability to accept her own responsibility or role in her recovery. The patient does not accept any responsibility for recovery or feels powerless to do so. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services or RTC. Per LOCUS, the patients score of 4 for risk of harm also supports treatment at Level 5 medically monitored residence-based services. Moreover, the requested 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 for the convenience of the patient or provider. Therefore, the requested 14 days of RTC services are medically necessary for 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.