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 eating disorder treatment level of care. Findings:  The physician reviewer found that 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. With regard to risk of harm, the records support a score of 4. The patient has serious risk of harm, due to current suicidal ideation with expressed intentions, demonstrated by a recent hospitalization for suicidal ideation with a plan to overdose on pills. She was contracting for safety.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to having to leave school for treatment of an eating disorder.  With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to diagnoses of major depression and anxiety. The patient has psychiatric symptoms that are disabling and which interact with and seriously impair her ability to recover from her eating disorder. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has a moderately stressful recovery environment due to significant disruption in life circumstances from COVID-19, leaving school for treatment of her eating disorder, and having a roommate with an eating disorder. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has challenges maintaining her relationships with her social and support system due to isolating herself. In terms of resiliency and treatment history, the records support a score of 4. The patient has had a poor response to treatment and recovery management, with multiple treatment attempts and relapses. She has trouble maintaining gains outside of intensive treatment setting, and previous treatment has not achieved complete remission or optimal control of symptoms even with repeated exposure. With regard to treatment acceptance and engagement, the records support a score of 3. The patient has limited desire or lacks confidence to change despite intentions to do so. Thus, the patient has a total score of 24. In this case, the recommended level of care is medically monitored residence-based services. Therefore, residential eating disorder treatment level of care is medically necessary for the 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.