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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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. Applying the LOCUS framework, the patient met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4) with homicidal and possible suicidal ideation at the time of step up to RTC from IOP. The records document that the patient expressed intention of killing a peer, obtained a kitchen knife, and was in the process of seeking out this person to kill him when staff apprehended him. On admission, the patient was able to contract for safety. The patients history of chronic suicidal and homicidal behavior or threats with current expressions or behavior represented a significant elevation from usual behavior. In addition, there was clear compromise of his ability to care adequately for himself. The provider documented that the patient was not compliant with medications and showed poor impulse control and judgment. For dimension 2, the patient demonstrated serious functional impairment (score 4), given his struggles with peers, especially during group interactions. At the time of step up to RTC, the patient demonstrated a serious decrease in the quality of his interpersonal interactions, which included impulsive and aggressive behaviors. For dimension 3, the patient has s significant comorbidity (score 3), considering his diagnosis of thrombocytopenia and suspected history of hyperammonemia, which required medical monitoring. Significant psychiatric symptoms and signs were present, such as paranoia, delusions, and negative symptoms, which are themselves debilitating and have an adverse effect on the course and severity of any co-existing substance use disorder. For dimension 4A, the patients recovery environment was moderately stressful (score 3) due to recent deterioration of interpersonal circumstances including intention to kill a peer. There was evidence of significant discord in family or other important relationships and alienation from social interaction. For dimension 4B, the patients recovery environment was minimally supportive (score 4). The records document that existing supports were unable to provide sufficient resources to meet material or emotional needs of the patient. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4). Previous treatment in IOP did not achieve complete remission of symptoms nor optimal control of symptoms even with intensive and repeated exposure. The patients symptomatology has persisted despite multiple treatment attempts at various levels of care. For dimension 6, the patient exhibited minimal engagement and recovery (score 4). The patient was rarely, if ever, able to acknowledge and accept reality of his psychosis and was at the contemplation stage of change. The patient had no desire to adjust behavior, but he may have recognized the need to do so. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. Per LOCUS, the patients scores of 4 for risk of harm and functional status support treatment at Level 5 medically managed residence-based services level of care. For these reasons, the psychiatric RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.