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

Nature of Statutory Criteria/Case Summary:The patient has requested reimbursement for partial hospitalization program (PHP) 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, this patient met the criteria for PHP services. For dimension 1, the patient was at moderate risk of harm (score 3) given her bipolar I disorder. The patient was extremely manic and psychotic such that she was attacked her father and threatening to kill herself. She took a medical leave from school. While on campus, the patient was noted to confront others and act in a volatile manner. During the PHP admission, she was noted to have episodes of punching the walls and yelling. No active suicidal ideation existed but extreme distress and history of suicidal behavior existed. Binge or excessive use of substances resulted in potential harmful behaviors in the past, but there have been no recent episodes. For dimension 2, the patient demonstrated moderate functional impairment (score 3) due to her psychiatric condition. The patient was on medical leave from college and she experienced intense conflicts with her parents. The patient exhibited significant disruption in her sleeping patterns and appetite with weight loss, but without a serious threat to her health. She also demonstrated significant deterioration in her ability to fulfill responsibilities and obligations. For dimension 3, the patient has significant co-morbidities (score 3) due to her substance usage of alcohol and cannabis. Her recent heavy usage of cannabis had clearly detrimental effects on her bipolar mood disorder and likely precipitated her manic episode with psychotic features. This usage has been temporarily arrested through use of the PHP. For dimension 4A, the patients recovery environment was moderately stressful (score 3) since the records document that the patient did not want to have her father involved in her treatment. The provider noted that the patient had episodes of crying and screaming at her father and about her father during the PHP admission. She was on medical leave from college and recently broke up with her boyfriend. There was easy exposure to drugs and alcohol amongst her peers. These problems support significant discord or difficulties in family or other important relationships, and significant transition causing disruption in life circumstances. For dimension 4B, the patients recovery environment provided limited support (score 3). The records document that the patient had an outpatient psychiatrist, but she disagreed with her father and about whether to involve him in her treatment. Usual sources of support were somewhat ambivalent, alienated, difficult to access, or had a limited amount of resources they were willing or able to offer when needed. For dimension 5, the patient showed moderate or equivocal response to treatment and recovery management (score 3) given her the patients lability and dysregulation with outbursts during the PHP admission. Current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient exhibited minimal engagement and recovery (score 3). The patient indicated that she did not have a substance use disorder that required treatment. The provider assessed the patient as being in the precontemplative stage of change. The patient had outbursts of anger towards treatment providers in the facility and she demonstrated difficulty understanding the concept of recovery and her role in her recovery. The patient had some variability, hesitation or uncertainty in acceptance or understanding of illness and disability. These findings give the patient a composite score of 21, which is consistent with medically monitored non-residence based services, such as PHP level of care services. Therefore, the PHP services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.