Appeal type: Medical Necessity
Decision: Overturned 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, the patient met the criteria for RTC services.For dimension 1, the patient was at serious risk of harm (score 4) due to fluctuating reports of suicidal ideation and self-harm urges throughout RTC, particularly with worsened eating disorder symptoms. Toward the end of treatment at RTC, the patient was transported to the emergency department for evaluation of her active suicidal ideation. The records document current suicidal ideation with expressed intentions and/or past history of carrying such behavior but without means for carrying out the behavior, or with some expressed inability or aversion to doing so. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her inability to attend school or work due to severe symptoms. The patient was isolative with significant withdrawal from almost all social interactions. There is report of significant withdrawal and avoidance of almost all social interaction. For dimension 3, the patient has major co-morbidity (score 4) considering her medical complications from her eating disorder including GERD, constipation, orthostatic hypotension, hypokalemia, and elevated liver function tests. The patients eating disorder has also disrupted her menstrual cycle. The patient was receiving nutrition through a nasogastric tube leading up to the time of her admission to the RTC. Additionally, the patient was using cannabis daily prior to admission. Medical conditions exist which were clearly made worse by the existence of the presenting disorder. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patient was isolated to home, relied heavily on her parents for support while maintaining a conflictual relationship with them. The patient also had easy access to cannabis at home. There is documentation of significant discord or difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment provided limited support (score 3). The patient was noted to isolate herself from most social supports and she maintained a conflictual relationship with her parents. A few supportive resources existed in current environment and may be capable of providing some help if needed. For dimension 5, the patient exhibited poor response to treatment and recovery management (score 4). The patient was able to restore her weight while in RTC, but then declined to the point of needing medical hospitalization for eating disorder with nasogastric tube feeds. The patient was unable to maintain gains attained in intensive treatment outside of a structured setting. The records document that previous or current treatment did not achieve complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 6, the patient showed limited engagement and recovery (score 3). The provider charted that the patient was anxious and experienced some difficulty engaging and accepting responsibility for her own recovery. The patient often left groups early due to panic symptoms. Overall, the patient had some variability, hesitation or uncertainty in acceptance or understanding of illness and disability. These findings give the patient a composite score of 25, which is consistent with medically monitored residence-based services. Additionally, the patient scored a 4 in risk of harm and functional status, which also supports medically monitored residence-based services. In terms of length of stay, the patient met the criteria for level 5B moderate intensity intermediate stay residential treatment program due to significant disturbance in interpersonal skills as well as serious impairment in expected role functioning at home, school, and work. 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 psychiatric RTC services were 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.