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

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. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm due to a history of bradycardia and hypotension related to starvation. Her continued behaviors of restricting food and losing weight demonstrated a clear compromise of ability to care for oneself. In terms of functional status, the records support a score of 3. The documentation noted moderate impairment due to significant disturbances in physical functioning in sleep and eating habits. While the patient had recent gains in function while participating in treatment in a structured setting, reaching a high of 93 pounds, she had lost weight since leaving inpatient level of care. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity due to the presence of a history of significant alcohol abuse. The patients medical complications from her eating disorder, including bradycardia, peptic ulcer disease, and orthostasis, had a very high likelihood of developing to a point that may require intensive medical monitoring. She has presented to the emergency department in the past with electrolyte derangements. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment due to living in an unfamiliar culture. She was living in the Dominican Republic for the past four years and reportedly felt socially and culturally isolated. With regard to level of support of the recovery environment, the records support a score of 4. The patient had minimal support in her environment. She had very few actual or potential sources of support available, as she was temporarily staying in North Carolina and did not appear to have a clear discharge plan. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment. She had one prior treatment episode and did not have significant sustained improvement. She had a history of worsening clinically at lower levels of care. Her current treatment had not achieved optimal control of symptoms, even with intensive or repeated exposure. With regard to treatment acceptance an engagement, the records support a score of 3. The patient demonstrated limited engagement in entering treatment voluntarily on at least two occasions, although she requested to leave treatment against medical advice without a clear discharge plan. She had some variability or uncertainty in acceptance or understanding of illness and disability due to difficulty complying with the recommended treatment plan. Thus, the patient has a total score of 26. In this case, the recommended level of care is medically monitored residential services. Therefore, RTC services were medically necessary for the treatment of this patient.