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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services at a facility that provides dieticians services, emotional freedom technique (EFT), acceptance commitment therapy (ACT), eye movement desensitization and reprocessing (EMDR), body image therapy, music therapy, equine-assisted therapy (EAT), fitness therapy, horticulture therapy, culinary arts therapy, and mindfulness/meditation. 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 does not meet the criteria for the requested specialty RTC services. For Dimension 1, the patient is at moderate risk of harm (score 3) given her significant suicidal ideation. However, there is no current intentions or past history of suicide attempts. This supports significant current suicidal ideation without intent or conscious plan and without past history. For Dimension 2, the patient has exhibited serious functional impairment (score 4). The records document that the patient was working prior to the onset of her symptoms and she continued to do so with some difficulty. This indicates an inability to perform close to usual standards in her work and record also suggest serious deterioration in other aspects of functioning, including lack of sleep. Serious disturbances in physical functioning such as disrupted sleep that threaten physical well-being. Also, an inability to perform close to usual standards in work and these responsibilities may be completely neglected on a frequent basis or for an extended period of time. For Dimension 3, the patient has minor comorbidities (score 2) as there is no indication of significant co-existing substance use or medical conditions that currently adversely affect her mental health condition. The patient is noted to have some substance misuse in the past. Occasional episodes of substance misuse, but any recent episodes are self-limited, show no pattern of escalation, and there is no indication that they adversely affect the course of a co-occurring psychiatric disorder.For Dimension 4A, the patients recovery environment is mildly stressful (score 2) considering the lack of significant stressors related to her current situation. The patient reported that she ended a relationship about one year ago, which may have precipitated some of her symptoms. Circumstances causing some distress such as a close friend leaving town, conflict in or near current residence, or concern about maintaining material well-being. For Dimension 4B, the patients recovery environment is highly supportive (score 1) due to the presence of a strong support system, for which the patient expressed gratitude. Plentiful sources of support with ample time and interest to provide for both material and emotional needs in most circumstances. For dimension 5, the patient has demonstrated significant response to treatment and recovery management (score 2) as the records indicate that past treatment was at least partially successful and allowed her to function without treatment for at least one year. Recovery has been managed for moderate periods of time with limited support or structure. For dimension 6, the patient has shown positive engagement and recovery (score 2) since the providers report she is well engaged in present treatment, but has some ambivalence or difficulty connecting to recommended care. She recognizes and understands her illness and demonstrates a desire for recovery. Although she has been limited in her acceptance of treatments that are available to her, she is eager to enter a program of her choosing. The patient has significant understanding and acceptance of illness and its effect on function. In addition, the patient has a positive attitude toward recovery and treatment, capable of developing trusting relationships, and uses available resources independently when necessary. These findings give the patient a composite score of 16, which is consistent with low intensity community-based services. The patients score of 4 on functional status supports treatment at Level 5, medically monitored residence-based services. The patient has requested specialty RTC services. However, the patients Health Plan has approved RTC services without add-on services such as EFT, ACT, EAT, and EMDR. As an in-network provider offered the patient Level 5 RTC services, and there is no indication that standard RTC services would be inadequate to address the patients medical needs, out-of-network RTC with add-ons is not medically necessary to meet the basic psychiatric needs of the patient. Therefore, the requested RTC services at a facility that provides dieticians services, EFT, ACT, EMDR, body image therapy, music therapy, EAT, fitness therapy, horticulture therapy, culinary arts therapy, and mindfulness/meditation are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.