Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 44-year-old male who was admitted to a residential treatment center (RTC) on 
5/2/23 and presented for an evaluation. The patient has requested authorization and coverage 
for residential treatment services from 5/25/23 and forward. The physician reviewer found that 
at issue is whether residential treatment services from 5/25/23 and forward were and/or are 
medically necessary for the treatment of this patient. 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. For dimension 1, with regard to risk of harm, the records support a score of 
3. The patient has a significant risk of harm, due to a history of excessive substance use resulting 
in potentially harmful behavior including legal trouble and incarceration. The patient displays 
periods of inability to self-care in his environment. The patient does not currently endorse 
suicidal ideation. For dimension 2, in terms of functional status, the records support a score of 4. 
The documentation notes serious functional impairment due to the patients inability to work 
due to his symptoms. The patient is in the process of applying for short term disability while in 
RTC due to an inability to work due to his symptoms. For dimension 3, with regard to comorbidity, 
the records support a score of 3. The patient has significant comorbidity due to the presence of 
substance abuse which, though temporarily arrested, has a significant adverse effect on his 
functioning and presenting condition, and impedes his recovery. For dimension 4A, in terms of 
the level of stress of the recovery environment, the records support a score of 4. The patient has 
a highly stressful environment due to severe disruption in his life circumstances as a result of a 
recent incarceration and separation from his wife and three children. The patient is isolated, with 
a restraining order against him. For dimension 4B, with regard to the level of support of the 
recovery environment, the records support a score of 4 as the patient has very limited social 
support, with only support from brother, and is separated from his wife and children. For 
dimension 5, in terms of resiliency and treatment history, the records support a score of 4. The 
patient has poor resiliency and/or response to services as a psychiatric hospitalization led to the 
patients admission to the RTC. Previous treatment for substance use has not  resulted in 
remission or optimal control of symptoms. For dimension 6, with regard to treatment acceptance 
and engagement, the records support a score of 3. The patient has some variability in acceptance 
of his illness and has trouble accepting responsibility for his recovery. Thus, the patient has a total 
score of 25. The records support a 4 in terms of functional status. In this case, the recommended 
level of care is medically monitored residence-based services. With the functional impairment 
noted, the patient meets LOCUS 5b extended stay criteria. Therefore, residential treatment 
services from 5/25/23 and forward were and are medically necessary for the treatment of this 
patient.