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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) 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 did not meet the criteria for RTC services. For dimension 1, the patient was at moderate risk of harm (score 3) due to no active suicidal ideation or homicidal ideation, but extreme distress and history of suicidal behavior exists. The patient was suicidal prior to admission due to severe psychosis. For dimension 2, the patient demonstrated moderate functional impairment (score 3) give her recent gains and stabilization in function have been achieved while participating in treatment in a structured setting. The patient had impairment in activities of daily living and inability to function in relationships when in a severe disorganized psychotic episode that was triggered by cannabis usage. She has responded to antipsychotics and her activities of daily living have improved significantly. For dimension 3, the patient has significant co-morbidities (score 3). The records document that the patient has been diagnosed with schizophrenia, major depressive disorder, and cannabis use disorder. The patients recent substance use has had clearly detrimental effects on the presenting disorder but was temporarily arrested through the use of a highly structured setting. The patient had a severe psychotic episode triggered by cannabis usage and has not used since being hospitalized. The records document that that patient has shown insight into the effect her cannabis usage has had on her condition. For dimension 4A, the patients recovery environment was mildly stressful (score 2) due to isolation due to the COVID-19 pandemic and difficulties with her daughter. The records document the presence of some ongoing or intermittent interpersonal conflict, alienation, or other difficulties. For dimension 4B, the patients recovery environment was supportive (score 2) since her husband and mother were provided support. The patients family participated in her treatment on a regular basis in the facility. This supports that some elements of the support system were willing and able to participate in treatment if requested to do so and had the capacity to effect needed changes. For dimension 5, the patient exhibited significant response to treatment (score 2). The patient was treated with an antipsychotic and an antidepressant with significant improvement in most of her symptoms. Per the provider, the patient was no longer experiencing psychosis. Based on the records, previous or current treatment has been successful in controlling most symptoms, but intensive or repeated exposures have been required. For dimension 6, the patient showed positive engagement and recovery (score 2). The records document that the patient had insight into her psychotic episode and that cannabis had triggered the episode. She was compliant with taking her medication and participating in recommended therapies. The patient showed significant understanding and acceptance of illness and its effect on her ability to function. This patients composite score is 17 which, is consistent with high intensity community-based services. Thus, the patient does not meet the LOCUS criteria for RTC services. Moreover, the RTC services were not in accordance with the generally accepted standards of mental health and substance use disorder care, and not clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the RTC services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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.