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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient testing for five to seven days at a specialty flex hospital and/or 90 days of specialized 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, this patient meets the criteria for inpatient testing for five to seven days at a specialty flex hospital and 90 days of specialized RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to mood lability as well as physical and verbal violence toward others in the home, school, and treatment settings. The patient has experienced legal issues related to their behavioral problems. The records indicate that the patient acknowledged in April 2022 that they needed detoxification and treatment due to their polysubstance use of fentanyl and cannabis. The patient reported that they have spent time with dangerous people. The patient has acknowledged homicidal ideation towards people who have facilitated their addiction to drugs. The records document 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. For dimension 2, the patient has demonstrated serious functional impairment (score 4) since they have been unable to keep a job, maintain healthy family or other social relationships, and has continued to struggle in the educational setting. The patient has shown consistent failure to maintain personal hygiene, appearance, and self-care near usual standards. The patient has exhibited serious decrease in the quality of interpersonal interactions with consistently conflictual or otherwise disrupted relations with others, which may include impulsive, aggressive, or abusive behaviors.  For dimension 3, the patient has major co-morbidity (score 4) including PTSD, anxiety, and unrelenting and dangerous substance abuse. The patient also has developmental disability concerns in the form of suspected learning disabilities including ADHD. The records document that psychiatric symptoms exist which are clearly disabling, and which interact with and seriously impair ability to recover from any co-occurring substance use disorder. For dimension 4A, the patients recovery environment has been highly stressful (score 4) with difficulty avoiding exposure to active users and other pressures to partake in alcohol or drug use. The patient is noted to have a history of altercations with family and others in the community. For dimension 4B, the patients recovery environment has provided minimal support (score 4). The records indicate that the patients parents have shown difficulty in assisting the patient with limit setting in the face of patients overwhelming substance use, deception, and violent outbursts. There is documentation that the existing supports are unable to provide sufficient resources to meet emotional needs. For dimension 5, the patient has shown negligible response to treatment (score 5). Overall, the patient has demonstrated negligible response to services at a lower level of care other than RTC to deal with stressors and triggers to dangerous and harmful behaviors. The patients treatment at lower level of intensity outside of RTC has not been successful in assisting patient to ameliorate their substance use problem and concomitant mood and behavioral issues. The patients past or current response to treatment has been quite minimal, even with intensive medically managed exposure in highly structured settings for extended periods of time. For dimension 6, the patient has shown limited engagement and recovery (score 3). The provider charted that the patient acknowledges substance use issues only superficially. The patient reported that their parents refuse to let them return home unless they participate in treatment. The patient has shown some variability, hesitation or uncertainty in acceptance or understanding of illness and disability. These findings give the patient a composite score of 28, which is consistent with Level 6 services. The patient has demonstrated concomitant risk of harm towards themselves and others and has a history of homicidal ideation when using substances. The patient has placed themself at risk of overdose due to their severe oxycodone and fentanyl use patterns. The patient has demonstrated a pattern of lying, engaging in fraud, and severe outbursts with inability to stop their substance use. Thus, the requested psychological testing is medically necessary for further diagnostic clarification and treatment direction of this patient. Moreover, the inpatient testing for five to seven days at a specialty flex hospital and 90 days of specialized 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 primarily for the convenience of the patient or provider. For these reasons, the requested inpatient testing for five to seven days at a specialty flex hospital and 90 days of specialized 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.