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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued residential treatment center (RTC) services (to begin immediately). 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 meets the criteria for continued RTC services to begin immediately. For dimension 1, the patient has been at serious risk of harm (score 4) since he has voiced need to defend himself against perceived intruders in the setting of this delusional system. He has clear compromise of his ability to care adequately for himself and to be adequately aware of his environment given his paranoia and subsequent misinterpretation of reality. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given his decline in ability to perform ADLs. The provider described the patient as disheveled on examination. The patient has deficits in interpersonal relationships. The patient has significant disturbances in physical functioning such as sleep, eating habits, activity level, or sexual appetite, but without a serious threat to health. For dimension 3, the patient has minor comorbidities (score 2) given his history of obesity and need for weekly blood draws to monitor his neutrophil count. The provider noted that the patient was fatigued with dry mouth and drooling as a result of treatment with Clozaril. This supports existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The patient has tension with his family as a result of his psychosis. His family has limited understanding of his need for regular lab monitoring. There is significant discord or difficulties in family or other important relationships. For dimension 4B, the patients recovery environment provides limited support (score 3) due to his familys limited understanding of his needs. The patient has an outpatient therapist and psychiatrist. Persons who have potential to provide support have incomplete ability to participate in treatment and make necessary changes. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4) since he has failed and previous treatment with an output psychiatrist. He is currently on Clozaril which is a medication for refractory psychiatric symptoms. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient has been minimally engaged (score 4) in his recovery. The patient has been adherent with treatment, yet he requires a great deal of encouragement and support to connect with treatment resources. The patient avoids contact with and use of treatment resources if left to his own devices. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services, such as RTC. Therefore, the requested RTC services (to begin immediately) are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are 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.