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 specializes in obsessive compulsive disorder (OCD) and that provides exposure response prevention (ERP). Findings:  The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adolescents 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 criteria, this patient presents with a low risk of harm (score 2) due to a lack of current active or passive suicidal ideation and recent risk assessment by psychiatrist that indicates this risk level. The progress notes do not describe any current suicidal or homicidal thoughts or any recent aggression. The patient has been demonstrating moderate functional impairment (score 3) given his inability to fulfill some responsibilities and some interpersonal issues along with recent unemployment. There was no indication that his activities of daily living were not intact. He does not appear to be experiencing any psychosis. The patient has no reported co-morbidities (score 1) due to no current substance use and no active medical issues. Recent progress notes indicate the patients primary issues are mood and OCD related. The patients recovery environment is mildly stressful (score 2) due to some minor relational issues with family due to his symptoms. The patients recovery environment is supportive (score 2) with family who is willing to provide aid. His family has been involved in his treatment. The records document that treatment has been partially successful (score 3) considering the patients recent resolution of suicidal ideation while on the inpatient psychiatric unit. The progress notes indicate he has required prior admissions to the acute inpatient psychiatric level of care over the past several years. The records report ECT trials in 2018. He stated that past medication trials were successful in controlling his symptoms. The patients engagement and recovery status has been positive (score 2) due to good cooperation in treatment, recent verbalization of insight into need for treatment, and his desire to continue therapy to decrease his symptoms. He has been cooperative with treatment overall and open and responsive to his providers. Recent progress notes indicate he has been future oriented and had several protective factors against suicide risk. He expressed motivation to obtain a job or volunteer. This gives the patients presentation a composite score of 15, which correlates with high intensity community based services. According to the patients score on the LOCUS, RTC is not indicated. Therefore, the requested RTC services at a facility that specializes in OCD and that provides ERP 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.