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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for partial hospitalization program (PHP) services for 30 days.Findings:  The physician reviewer found that 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 does not meet the criteria for PHP services. For dimension 1, the patient is at low risk of harm (score 2) due to lack of current suicidal or homicidal ideation, plan, intentions or severe distress, but may have had transient or passive thoughts about recently or in the past. There is documentation of periods in the past of self-neglect without current evidence of such behavior. There is no record of vital sign instability or electrolyte abnormalities. She is eating and weight has trended up since discharge from the intensive outpatient program (IOP). For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. The patient is married and lives with her husband, grandmother, and uncle. She does not work. The most recent report indicated that she was noting decreased appetite and increased sleep. She has moderate impairment as evidenced by significant disturbances in physical functioning such as sleep, eating habits, activity level, but without serious threat to health. For dimension 3, the patient has minor comorbidities (score 2). The patients primary condition is anorexia nervosa. She has comorbidities including headaches and spina bifida with back pain and neurogenic bladder. She does not use substances and there is no evidence of hypotension, bradycardia, or electrolyte disturbances. There is existence of medical problems which are not themselves immediately threatening and which have no impact on the course of the presenting disorder.  For dimension 4A, the patients recovery environment is mildly stressful (score 2) as she noted that she is often alone during the day and her husband has some mental health problems. There have been no significant losses or transitions noted. This supports the presence of some ongoing interpersonal conflict or other difficulties. For dimension 4B, the patients recovery environment provides limited support (score 3). The records document that the patient has a few supportive resources in current environment that may be capable of providing some help if needed. The patients family is supportive of her getting treatment. She is currently receiving treatment from her primary care provider, nutritionist, therapist and psychiatrist, but she feels that she needs a higher level of care. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3) since she has gained a small amount of weight since discharge from the IOP. She still reports substantial fear of gaining weight and of eating the prescribed amount of food. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms.  For dimension 6, the patient has showed positive engagement and recovery (score 2) considering her ability to attend scheduled IOP appointments since late 2019. The provider described the patient as engaged in treatment. The patient has a positive attitude toward recovery and treatment, capable of developing trusting relationships, and uses available resources independently when necessary. These findings give the patient a composite score of 17, which is consistent with high intensity community-based services, or IOP. For these reasons, the requested PHP services are not medically necessary. Final Result: The reviewer determined that the requested services are 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.