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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP). 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. With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to endorsing passive suicidal ideation and continued urges to self-harm. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to difficulty functioning without significant support and prompting, neglecting his personal hygiene, and having trouble in any social environments without the support of staff. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to the presence of obesity and hypertension, and a potential for metabolic syndrome and fatty liver disease requiring ongoing monitoring. The patients psychiatric medication increased his appetite. The records noted a diagnosis of autism spectrum disorder complicating the patients social interactions. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient had a moderately stressful environment due to having to start college classes to retain his spot following a mental health deferral. The patients family was noted as being supportive, although far away in California while patient was in treatment in Wisconsin. The records noted that the patient perceived a great deal of pressure to succeed from his mother, and this surpasses his ability to meet obligations. With regard to level of support of the recovery environment, the records support a score of 3 as the patients family was supportive, although far away in California while the patient was being treated in Wisconsin. The patient was socially isolated when left to his own devices, avoiding others due to symptoms of obsessive compulsive disorder. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management, struggling consistently despite treatment at residential treatment center, PHP, and intensive outpatient program levels of care and transcranial magnetic stimulation therapy.With regard to treatment acceptance and engagement, the records support a score of 3. The patient had a great deal of trouble in the group setting, easily becoming overwhelmed and isolating himself. He relied heavily on staff members to assist with his recovery but seemed to be engaged and motivated in treatment.  Thus, the patient has a total score of 22. In this case, the recommended level of care is medically monitored community-based services. In this patients case, PHP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, PHP was medically necessary for the 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.