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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 30-day residential treatment center (RTC) program.  Findings:  The physician reviewer found that 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 does not meet the criteria for 30-day RTC level of care program services. For dimension 1, the patient is at moderate risk of harm (score 3) given his binge episodes of methamphetamine use that result in psychosis as recently as May 2020. He is not suicidal or homicidal. The patients binge 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 mild functional impairment (score 2) due to his depression, which the provider characterized as being in partial remission, and alcohol and amphetamine use disorder in early remission. The patient has exhibited minor disruptions in aspects of self-care or usual activities. Recent experience of some minor disruptions in aspects of self-care or usual activities. For dimension 3, the patient has significant comorbidities (score 3). The provider noted that the patient has a diagnosis of major depression and a history of trauma. The patient reported that he relapsed on methamphetamine following the death of a friend. Significant psychiatric symptoms and signs are present which are themselves somewhat debilitating, and which interact with and have an adverse effect on the course and severity of any co-occurring substance use disorder. For dimension 4A, the patients recovery environment is moderately stressful (score 3) given his easy exposure and access to alcohol and drug use. For dimension 4B, the patients recovery environment provides limited support (score 3) considering his dissatisfaction with his current treatment options. Although the patients parents are supportive, he is delusional about them in a constructive manner. A few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has shown moderate or equivocal response to treatment and recovery management (score 3). He has had previous treatment of his methamphetamine and alcohol use disorder. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms.For dimension 6, the patient has demonstrated positive engagement and recovery (score 2) given his significant understanding and acceptance of illness and its effect on function. These findings give the patient a composite score of 19, which is consistent with high intensity community-based services, such as intensive outpatient program (IOP) level of care. Therefore, the requested 30-day RTC level of care program is 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 with subspecialty certification in addiction medicine 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.