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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for all or any of the residential treatment center (RTC) services provided by A Mission for Michael. 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 4. The patient has a serious risk of harm, due to continued suicidal ideation, even if passive at times, and a history of a serious suicide attempt resulting in hospitalization.In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient has been unable to work for two years and dropped out of her graduate program due to symptoms of depression. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to hypothyroidism from taking lithium in the past, which can affect her ability to stabilize her mood, and a history of ovarian cancer and medication-induced seizures, limiting her course of medication options while in treatment.  In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has a highly stressful environment due to an inability to work or to manage a graduate program while living in a home with seven roommates and having to navigate both biological and adoptive family stressors. The records noted that the patients biological mother passed away earlier this month, leading to further stress.  With regard to level of support of the recovery environment, the records support a score of 3 as the patient lived with seven roommates with an unclear level of support from them and has conflictual relationships with both her adoptive and biological families.  In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment, as she has continued significant symptoms and has not achieved complete remission of symptoms despite prior RTC, PHP, and IOP attempts. With regard to treatment acceptance and engagement, the records support a score of 3. The patient has very limited coping skills and consistently conflictual relationships. Thus, the patient has a total score of 24. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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, RTC services provided by A Mission for Michael were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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.