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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center level of care. He has a diagnosis of schizophrenia; paranoid type. His health history includes a traumatic brain injury and hip injury. He has been hospitalized many times due to his mental health issues and has been arrested. He has historically been non-compliant with his medication regimen. During his most recent incarceration, his psychiatrist determined he was a danger to himself and others. He did not believe the enrollee could manage his mental health issues without 24-hour supervision, so the enrollee was referred to a residential treatment facility. He was treated with individual therapy, and was encouraged to attend groups and perform community activities. Medications included Zyprexa and Geodon. The discharge plan summary indicated the enrollee was offered twelve weeks of satellite services when he left the program. The plan was for him to continue his psychiatric care and continue with the Geodon as prescribed. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. LOCUS criteria indicate residential treatment is medically necessary when there is a Level 5 need for opioid treatment services, and/or Level 6 need for withdrawal management services. The composite score necessary for level 5 admission is 23  27; level 6 would be 28 or more. This enrollees total LOCUS score is 26. Risk score is 3, which is moderate risk. He did not express any direct thoughts of harm to himself or others, but he does display paranoid thoughts and has demonstrated violent outbursts. His functional status score is 4, which is serious impairment. He displays an unawareness of his mental state, demonstrates a self-care deficit as evidenced by his inability to keep himself or his surroundings clean, and he is non-compliant with his medication regimen, which could help moderate this symptomology. He has a severe co-morbidity, resulting in a score of 5 for this metric, due to his paranoid thoughts, substance abuse history and inability to follow medication regimens and protocols. His history of incarceration, violence, and hospitalizations contributed to a score of 4 for treatment and recovery history. His lack of engagement with his treatment plan and lack of awareness of his disease state is 5 for engagement. The enrollee met criteria for RTC services for the full duration of the period in question.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child & adolescent 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 similar medical condition.