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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for 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. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to a recent history of serious suicide attempt in January 2022 when the patient stabbed herself. The records noted a history of suicidal ideation along with poor insight and judgment. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient is very isolative with significant withdrawal from almost all social interactions, relying on her husband to financially support her, and with difficulty engaging with others. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of self-inflicted abdominal wounds that are still healing from recent suicide attempt, along with severe constipation.  In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has a highly stressful environment as she is significantly isolated but unable to care for herself. She is separated from her husband and two children. She is in the process of leaving her apartment, where she attempted suicide. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has very limited support, relying heavily on her husband, from whom she is divorcing, and without other social supports. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, due to a history of psychiatric hospitalizations and RTC attempts, with limited ability to maintain gains outside of intensive treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient is withdrawn and difficult to engage in treatment, with limited ability to accept responsibility for her recovery. Thus, the patient has a total score of 25. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets LOCUS 5b extended stay criteria. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, RTC services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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.