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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the 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. With regard to risk of harm, the records support a score of 3. The patient had a moderate risk of harm, due to suicidal ideation without intent or plan, and evidence of self-neglect and/or decrease in the ability to care for oneself due to struggles with ADLs, such as cooking, shopping, showering, and hygiene. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to depressive symptoms, such as struggles with disrupted sleep and fatigue. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to major depressive disorder.  In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to the recent losses of her grandmother and her father, and conflict with her mother. With regard to level of support of the recovery environment, the records support a score of 3 as the patient found interactions with her mother challenging and stressful.  In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment, with depression worsening prior to admission despite having participated briefly in substance abuse treatment, and taking multiple psychotropic medications for depression, anxiety, and ADHD.With regard to treatment acceptance an engagement, the records support a score of 3. The patient expressed motivation to change and make progress in her recovery, but also struggled to follow through on assignments and daily tasks. Thus, the patient has a total score of 22. In this case, the recommended level of care is medically monitored residence-based services due to her functional status score of 4. Therefore, all of the RTC services provided were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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.