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

Findings:  The physician reviewer found that : 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 LOCUS criteria for RTC services.For dimension 1, the patient has been at moderate risk of harm (score 3) due to denial of suicidal ideation and homicidal ideation, since the patient also denies all other symptoms and has no insight. The patient reports having used cannabis daily, which resulted in potentially worsened psychotic symptoms. The patient was impulsive and inappropriate prior to admission. The patient has continued to be awkward and unable to function socially throughout the RTC stay. The records document binge or excessive use of substances resulted in potentially harmful behaviors in the past, but there have been no recent episodes. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given a great difficulty functioning normally and communicating due to active psychotic symptoms. The patient denies having active psychotic symptoms, but the providers have documented these symptoms are still present. In addition, the patient has been isolative. There is evidence of significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has significant comorbidities (score 3) considering the significant daily cannabis use leading up to admission to inpatient with detrimental effects on psychotic symptoms. 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 has been highly stressful (score 4). The records document that the patient endorsed verbal abuse from parents, with whom they live and is otherwise socially isolated. The patient has been more withdrawn and with easy access to cannabis, which has worsened symptoms. There is support of difficulty avoiding exposure to active users and other pressures to partake in alcohol or drug use. For dimension 4B, the patients recovery environment provides minimal support (score 4) due to the presence of very few or actual sources of support available. The patient also cites ongoing verbal abuse from parents with whom they live. Overall, the patient has very few actual or potential sources of support available. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4). The patients previous treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. The provider noted that the patient continues to be quite psychotic with limited insight. For dimension 6,  the patient is unengaged and stuck in treatment (score 5). The available documentation indicates that the patient has no insight into this illness and is unable to understand contributions to the disease process. The patient has no awareness or understanding of illness and disability. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services or RTC. 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 substance use temporarily arrested in a highly structured setting but with difficulty maintaining that outside of such a setting. 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. All told, the RTC services were and are medically necessary for 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.