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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, and authorization and coverage, for dual diagnosis 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.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. The patient has ongoing passive suicidality and hopelessness. He has made seven suicide attempts in the past year and the most recent one led to his involuntary admission. These attempts occurred when the patient was heavily intoxicated on alcohol and were impulsive. The patient also had suicidal thoughts of hanging himself while he was an inpatient. The patient therefore has a history of chronic impulsive suicidal behavior, and 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. [Score 4  serious risk of harm]For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. The patient was living with his mother but he is not able to return there due to his substance usage and self-harm. He has been socially isolating and reports his relationships with his mother, sister, and girlfriend are strained. The patient meets the criteria of serious decrease in the quality of interpersonal interactions with consistently conflicted relations with others, and significant withdrawal and avoidance of almost all social interactions. [Score 4  serious impairment]For dimension 3  Comorbidity. 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. While the patients primary condition is bipolar depression, he has comorbidities of alcohol use disorder and cannabis use disorder. The patient reported that he drinks 10 shots of vodka most days and has attempted suicide seven times in the past year while intoxicated. He reports drinking and smoking cannabis in order to treat his anxiety. The patient meets criteria of uncontrolled substance use that occurs at a level which poses a serious barrier to recovery from any co-existing psychiatric disorder. [Score 4- major co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient has a highly stressful environment, as he has significant discord with his mother over his substance usage and depression. The patient meets the criteria of having severe disruption in his life circumstances such as losing housing. [Score 4 highly stressful environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient's family is supportive of his getting treatment, and he is currently receiving treatment from an outpatient psychiatrist. Considered in total, the patient has few supportive resources in his current environment that may be capable of providing some help if needed. [Score 3- limited support in environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient had his first episode of depression three years ago. His suicidality has worsened, and he started attempting suicide nine months ago. He has had a poor response to treatment with previous or current treatment not achieving optimal control of his symptoms even with intensive or repeated exposure. [Score 4- poor response to treatment and recovery management]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient has been in treatment for bipolar depression and has had numerous psychiatric admissions over the past year. Records reflect that the patient is now willing to change and is actively working to this end. [Score 2- positive engagement and recovery]These findings give the patient a composite score of 25, which corresponds with Level 5, Medically Monitored Residential Services. Level 5 is consistent with a dual diagnosis Residential Treatment Center (RTC) level of care. Accordingly, the requested dual diagnosis Residential Treatment Center (RTC) services at issue and requested services were, and are, medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary for the patient's 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.