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 any or all a residential treatment center (RTC) level of care services. Findings:  The physician reviewer found that he 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 3. The patient has a significant risk of harm, as he has a recent inpatient hospitalization due to progressively worsening auditory hallucinations telling him to kill himself by stabbing himself. The records did not document a history of suicide attempts or current suicidal ideation with plan or intent. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient was disruptive and inappropriate in the RTC. The patient was noted as being impulsive and having a conflictual relationship with his mother, who has told him that he is not allowed to return to live at his parents home. The patient is unable to perform close to his usual standards, to find employment, or to manage his responsibilities.  With regard to comorbidity, the records support a score of 1. The patient has no comorbidities. 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 he was initially told by his mother that he could return to living with his parents if he completed treatment but is now no longer welcome home and is thus without housing. With regard to level of support of the recovery environment, the records support a score of 4 as the patient depends heavily on his mother, who is unwilling to continue giving him support. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as previous inpatient hospitalization has not achieved complete remission of symptoms as the patient continues to have significant symptoms and is unable to maintain a job because of these symptoms. With regard to treatment acceptance and engagement, the records support a score of 3. The patient has some variability in acceptance of his illness due to recently being diagnosed with a psychotic illness. The records noted that the patient required redirection by staff in RTC. Thus, the patient has a total score of 23. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment 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 level of care 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.