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.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. At the time of admission, the patient had developed ongoing difficulties with suicidal ideation and impulsive behaviors but had no implemented plan in the past. She was not actively suicidal, but had sporadic episodes of suicidal ideation during the course of her stay. While the patient had a history of chronic impulsive suicidal ideation, her current expressions during the period at issue did not represent significant change from usual behavior. [Score 3  Moderate Risk of Harm]For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interact with others, maintain their physical functioning and their capacity for self-care. The patient had a pattern of verbal and sometimes physical aggression, and her anxiety and disrupted thinking led to an inability to function close to her usual standards at work and other obligations. During the course of treatment she was able to control these impulsive behaviors, and her progress was such that she was able to maintain control of any impulsive, aggressive or abusive behaviors. [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. Records indicate that the patient had no significant substance use and no medical conditions that impacted her psychiatric condition. [Score 2  Minor Co-Morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. Notes indicate that the patient had no significant stressors apart from some ongoing interpersonal conflict or alienation. [Score 2  Mildly Stressful Environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the recovery environment. Records reflect that the patient had a very supportive family and some friendships that were supportive, but these sources were not abundant. [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 record indicates that the patient had several past treatment experiences and medication trials. While she responded to these measures at times, she was not always happy with outcomes, especially with regard to medication. The patient was not able to maintain significant recovery for an extended period. [Score 3  Moderate or Equivocal Response to Treatment and Recovery Management]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and ability and willingness to engage in the treatment process. The record indicates that the patient was well engaged in her treatment and in a change process. The patient had an understanding and acceptance of her illness and its effect on her ability to function. [Score 2  Positive Engagement and Recovery]Thus, the patient has a composite score of 17 for the period of residential treatment center services at issue. This composite score corresponds with a Level 3: High Intensity Community Based Services level of care. Accordingly, the residential treatment center (RTC) services at issue were not medically necessary to treat the patients medical conditions of emotional dysregulation, chronic suicidal ideation, mood disorder with intermittent psychotic symptoms, and eating disorder behaviors.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients medical conditions. 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.