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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services.At issue is whether the Residential Treatment Center (RTC) services at issue were medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).California Health and Safety Code section 1374.72(a)(3)(A) states that Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i)In accordance with the generally accepted standards of mental health and substance use disorder care.(ii)Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii)Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.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- Risk of Harm. This dimension assesses potential for harm to self or others. There is no indication in the records of any current suicidal ideation at the time of admission nor was there any evidence of any significant thoughts of self-harm in the past. This qualifies the patient for low risk of harm in this dimension. [Score 2  Low Risk of Harm].For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with, maintain physical functioning and capacity for self-care. Records indicate that despite some associated anxiety, the patient displayed perfectionistic behaviors and was a very high functioning high achiever. Although the patient restricted food intake and had some menstrual dysfunction, her weight loss did not pose a serious threat to her health. This qualifies the patient for moderate impairment in this dimension. [Score 3  Moderate Impairment] For dimension 3  Comorbidity. 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 presented for treatment for anorexia nervosa, a psychiatric condition. She had no significant substance use history and only minor disruption of physical functioning that did not impact her psychiatric issues. This qualifies for minor comorbidity in this dimension. [Score 2  Minor Co-Morbidity] For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient had experienced some minor stress related to high expectations regarding her performance and some conflict with her mother. This qualifies as a mildly stressful environment. [Score 2  Mildly Stressful Environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient had a close relationship with her father and siblings, and although there was some tension between the patient and her mother, she was well supported at the time of admission. This qualifies as a supportive environment for this dimension. [Score 2 Supportive Environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient had some past treatment and was briefly hospitalized about a year prior to this admission. Records reflect that the patients symptoms were not well resolved. This qualifies for moderate or equivocal response to treatment and recovery management for this dimension. [Score 3  Moderate or Equivocal Response to Treatment and Recovery Management] For dimension 6  Engagement. This dimension assesses a patients understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. Records reflect that the patient was able to engage with treatment providers and was motivated to change. Based on this, the patient qualifies for positive engagement and recovery in this dimension. [Score 2  Positive Engagement and Recovery]Thus, the patient has a composite score of 16, which corresponds with Level 2: Low Intensity Community Based Services level of care. This level of care provides treatment to clients who need ongoing treatment, but who are living either independently or with minimal support in the community.The patients scores under the six LOCUS dimensions take into account the specific needs of the patient for the purpose of treating their illness and its symptoms. The LOCUS framework for determining the appropriate level of care for adults needing mental health treatment is consistent with generally accepted standards of mental health, and it provides determinations that are clinically appropriate in terms of type, frequency, extent, site, and duration. The LOCUS dimensions are also free from consideration of the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the Residential Treatment Center (RTC) services at issue were not medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue were not medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). 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.