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

Nature of Statutory Criteria/Case Summary: The patients parent 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 criteria, this patient met the requirements for the RTC services.For dimension 1, the patient was at moderate risk of harm (score 3) given the lack of report of suicidal ideation at the time of admission, but periods of extreme distress and aggression emerged. The records document no active suicidal ideation, but extreme distress and/or a history of suicidal behavior existed. For dimension 2, the patient demonstrated serious functional impairment (score 4). The provider noted that the patient initially showed variably severe functional impairment with disruptions of interpersonal interactions with aggressive behaviors during first two weeks. The patient showed a serious decrease in quality of interpersonal interactions with consistently conflictual or otherwise disrupted relations with others, which may include impulsive, aggressive or abusive behaviors. For dimension 3, has significant co-morbidity (score 3). The records document that the patients presenting disorder was psychiatric. The patients diagnoses include bipolar disorder, current or most recent episode with manic, with psychotic features, alcohol use disorder, and amphetamine use disorder. The patient has significant medical issues and a history of substance use. There is report of ongoing or episodic substance use occurring despite negative consequences with significant or potentially significant negative impact on the course of any co-occurring psychiatric disorder. For dimension 4A, the patients recovery environment was highly stressful (score 4) given the patients history of family conflict, homelessness, and abuse. These circumstances did not significantly change through the course of the patients residential treatment, although some planning was occurring to reduce their impact. There is documentation of serious disruption of family milieu and severe disruption of life circumstances. For dimension 4B, the patients recovery environment provided minimal support (score 4). The provider noted that the patients severe conflict with and experience of abuse by her parents indicated minimal support, and this circumstance did not substantially change during the course of her stay. The patient indicated that her mother was supportive at times. The patient did not have any other sources of support. The records document that the usual supportive resources display little motivation or willingness to offer assistance, or they are themselves troubled or hostile toward the patient. For dimension 5, the patient exhibited poor response to treatment and recovery management (score 4). The patient has undergone multiple hospitalizations and used many different medications without significant periods of recovery since age 18. She has demonstrated recurring psychotic episodes, and limited insight into her illness during those periods. Although the patient showed some gains during the early part of her admission, given her history, this does not support moderate response to treatment. Based on the records, 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 showed limited engagement and recovery (score 3) due to inability to adhere to her plan of care. The patient was partially amenable to treatment during the early part of her stay. However, the variability of the patients understanding and the transience of her relationship with her care providers support only limited engagement. The patient had some variability, hesitation or uncertainty in acceptance or understanding of illness and disability, and the patient related to treatment with some difficulty and established few, if any, trusting relationships. These findings give the patient a composite score of 25, which is consistent with LOCUS Level 5 services. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the RTC services were and are medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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.