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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage 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 meets the criteria for RTC services. For dimension 1, the patient is at serious risk of harm (score 4) due to reported persistent suicidal ideation over the last month, as evidenced by the patients use of emergency department services and crisis line due to intensifying suicidal ideation to jump out of a window or to hang himself. The records document a history of chronic impulsive suicidal/homicidal behavior or threats with current expressions or behavior representing a significant elevation from usual behavior. For dimension 2, the patient has demonstrated serious functional impairment (score 4) since he is not currently functioning well, unable to work due to his symptoms, and he has been completely isolating himself. As of beginning of September 2021, the patient was no longer able to work due to progressively worsening symptoms. The patient has shown a significant withdrawal and avoidance of almost all social interaction.For dimension 3, the patient has significant comorbidities (score 3). The provider noted that the patient requires use of a catheter and he has a history of asthma and bicuspid aortic valve. Medical conditions exist or have potential to develop (such as diabetes or a mild physiologic withdrawal syndrome), which may require significant medical monitoring. For dimension 4A, the patients recovery environment is moderately stressful (score 3) considering his lack of social support. The patients perception that pressure to perform surpasses ability to meet obligations in a timely or adequate manner.For dimension 4B, the patients recovery environment provides minimal support (score 4). The provider noted that the patient has been completely socially isolated, not accessing support from his family and without further supports outside his family. Overall, very few actual or potential sources of support are available. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4) given previous treatment in outpatient and IOP without optimal control of symptoms. 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 has shown minimal engagement and recovery (score 4) due to reports that the patient has been difficult to engage by his providers, making his own demands of treatment and with difficulty accepting responsibility for his own recovery. The records document that the patient does not accept any responsibility for recovery or feels powerless to do so. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. Per LOCUS, the patients scores of 4 for risk of harm and functional status also support treatment at Level 5 medically monitored residence-based services level of care. For these reasons, the requested RTC services requested are medically necessary for treatment of this patient. Per LOCUS, in terms of length of treatment in a medically monitored residence-based program, the patient meets the criteria for moderate intensity intermediate stay residence-based  treatment program with length of stay of up to 60 days. Moreover, the requested RTC services are 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 requested RTC services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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.