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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The enrollee has also requested reimbursement and authorization and coverage for partial hospitalization program 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 composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. On the dates in question, the patient continued to restrict food and over-exercise, and she only weighed 88 lbs.. The patient had previously had bradycardia and hyponatremia due to water loading and severe food restriction. Therefore, there was some evidence of self-neglect by the patient as well as a decrease in her ability to care for herself in her current environment. [Score 3  moderate]For dimension 2  Functional Status. The patient was noted to have ongoing difficulties with food restriction and over-exercising while in the treatment program. She had only gained four pounds while at the inpatient level of care. She therefore had serious disturbances in physical functioning such as weight changes that threatened her physical well-being. [Score 4  serious impairment]For dimension 3  Comorbidity. This patient had complications of her eating disorder that included hyponatremia, bradycardia, and osteoporosis with stress fractures from compulsive exercising. Medical conditions therefore existed which were created or adversely affected by the existence of the patients presenting disorder, and medical conditions had a very high likelihood of developing which would require significant medical monitoring. [Score 3- significant co-morbidity]For dimension 4A - Recovery Environment - Stress. The patient had a moderately stressful environment. The patient was confronted by her family with an intervention regarding her anorexia. She was on medical leave from work. She was socially isolated due to COVID-19 and lost a significant amount of weight in the past three months. She also had a sustained worsening in her anorexia for the past six years, which she attributed to school and the level of stress. She therefore had significant discord or difficulties in her family relationships, and there was concern related to her sustained decline in health status. [Score 3 -moderate]For dimension 4B - Recovery Environment - Support. The patient had a supportive environment, as she had a psychologist who she was working with who recommended that she have more intensive treatment for her eating disorder due to her decline. She therefore had some elements of her support system who were willing and able to provide significant aid in times of need. [Score 2- mild]For dimension 5- Treatment and Recovery History. The patient had one prior intensive treatment episode prior to this one, and she did not have sustained improvement. The patient only gained four pounds in the inpatient level of care, and she was continuing to struggle with compulsive exercise and urges to restrict. Previous treatment had therefore not achieved optimal control of the patients symptoms even with intensive or repeated exposure. [Score 4- poor response]For dimension 6  Engagement. The submitted records reflect that the patient entered treatment voluntarily at the request of her family, but she was clearly afraid to adjust her behaviors. The patient had tremendous difficulty, and at times, she was not willing to follow the recommended treatment plan. The patient was therefore afraid to adjust her behavior, but she may have recognized the need to do so. [Score 4- minimal engagement]These findings give the patient a composite score of 23, which is consistent with Level 5 (Medically Monitored Residential Services). Accordingly, the residential treatment center services at issue were medically necessary to treat the patients condition.Regarding the following period, relating to the requested partial hospitalization program services, the patients composite score would be 20. The patients scores during this period would only change for three dimensions. The patients score for dimension 1 (Risk of Harm) would be 2 (low risk of harm), as the patients weight has increased to 105 pounds, thereby reflecting past self-neglect without current evidence of such behavior. The patients score for dimension 2 (Functional Status) would be 3 (moderate impairment), as recent gains had been achieved while participating in treatment in a structured setting. The patients score for dimension 5 (Treatment and Recovery History) would be 3 (moderate response), as she was able to achieve some of her weight restoration goals such that partial recovery had been maintained for moderate periods of time but only in a structured setting. The composite score of 20 for this subsequent period is consistent with Level 4 (Medically Monitored Non-Residential Services). Accordingly, the requested partial hospitalization program services were, and are, medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat 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.