Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 20-year-old female with a history of depression, suicidal ideation, borderline personality disorder, anxiety disorder, and polysubstance dependence. She presented for an assessment on 9/11/20. The patient has requested reimbursement for residential treatment provided from 10/20/20 through 11/04/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.  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 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 met the criteria for residential treatment. With regard to dimension 1 (risk of harm), the records support a score of 4. The patient had a suicide attempt prior to admission in which she cut herself and required sutures. On admission to the residential treatment center, she continued to have suicidal ideation and endorse hopelessness. 
In terms of dimension 2 (function), the records support a score of 4. This dimension assesses the degree to which a patient is able to fulfill social responsibilities, interacts with, maintain physical functioning and capacity for self-care. The patient was kicked out of college for her substance use and is now unemployed. The records noted that the patient was isolating herself. She had a conflictual relationship with her parents and an inability to function prior to admission to residential treatment center. With regard to dimension 3 (comorbidity), the records support a score of 3. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient was using cannabis so heavily that she was expelled from school and continued to use this and Xanax daily, despite the clear negative consequences on her health, both physically and mentally. In terms of dimension 4A (level of stress of the recovery environment), the records support a score of 4. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patient had to move back home after being expelled from college. She had serious disturbances in her family relationships and was isolating herself from social relationships. With regard to level 4B (level of support of the recovery environment), the records support a score of 3. This dimension assesses the presence of family and social support to augment the recovery environment. The patientas parents want to help the patient, but she has maintained a very conflictual relationship with them. She has also isolated herself from her other social supports. In terms of dimension 5 (treatment and recovery history), the records support a score of 4. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient was hospitalized psychiatrically following her suicide attempt and has been in outpatient treatment since then, but with minimal response to treatment thus far. With regard to dimension 6 (engagement), the records support a score of 4. This dimension assesses a patientas understanding of the illness and treatment, and ability and willingness to engage in the treatment process. The patient had trouble accepting her role in recovery and taking ownership and accountability of her own role in her conflictual relationships and course of her schooling and life. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. Per LOCUS, the patientas scores of 4 for risk of harm and also 4 for functional status also support treatment at Level 5 medically monitored residence-based services level of care. Therefore, residential treatment provided from 10/20/20 through 11/04/20 was medically necessary for the treatment of this patient.