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 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 meets the criteria for the RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to a history of a suicide attempt plus passive suicidal ideation throughout the beginning of her RTC treatment. The patient has shown difficulty in affect dysregulation, impulse control, agitation, and extreme distress. The records document current suicidal ideation with a past history of carrying out such behavior but without means for carrying out the behavior, or with some expressed inability or aversion to doing so. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given her inability to attend school or work due to severe symptoms. The patient is isolative with significant withdrawal from almost all social interactions. The patient is noted to become easily dysregulated even while in treatment. The patient has shown a 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 significant co-morbidity (score 3) considering her recent substance use of cannabis with detrimental effects on her mood symptoms and has been temporarily arrested while in the RTC. The records document recent substance use which has had clearly detrimental effects on the presenting disorder, but which has been temporarily arrested through use of a highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The provider noted that the patient is isolated to home but with easy exposure and access to substance use at home. There is evidence of significant discord or difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment has provided limited support (score 3) due to the patients conflicted relationship with her father. In addition, the patients mother is noted to enable the patient. The records indicate that the persons who have potential to provide support have incomplete ability to participate in treatment and make necessary changes. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4). The records document that the patient has been hospitalized or in treatment settings numerous times since age 13 and she has been unable to maintain gains made outside of a structured treatment setting. Attempts to maintain whatever gains that can be attained in intensive treatment have limited success, even for limited time periods or in structured settings. For dimension 6, the patient has shown minimal engagement and recovery (score 4). The provider charted that the patient has great difficulty accepting any responsibility for recovery, avoids group and individual therapy, and sabotages her treatment. The records indicate that the patient rarely, if ever, is able to accept reality of illness or any disability that accompanies it but may acknowledge some difficulties in living. These findings give the patient a composite score of 25, which is consistent with medically monitored residence-based services. The patients scores of 4 in risk of harm and functional status also support medically monitored residence-based services. Additionally, in terms of length of stay, the patient meets criteria for level 5B moderate intensity intermediate stay residential treatment programs due to significant disturbance in interpersonal skills as well as serious impairment in expected role functioning at home, school, and work. Moreover, the RTC services were and 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 RTC were and are medically necessary for treatment of this patient based on the provided documentation.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.