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 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. 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 has been at serious risk of harm (score 4) due to a history of a recent suicide attempt by overdose, resulting in hospitalization and continues to have suicidal ideation and self-injurious ideation with self-injury even while in RTC. The patient has poor coping skills and chronic impulsive suicidal behavior. The records support a history of chronic impulsive suicidal behavior or threats with current expression or behavior representing a significant elevation from usual behavior. For dimension 2, the patient has demonstrated serious impairment (score 4) given her inability to attend school or work due to severe symptoms. The patient is socially withdrawn due to recent substance use. The patient has shown inability to perform close to usual standards in school, work, parenting, or other obligations and these responsibilities may be completely neglected on a frequent basis or for an extended period of time. For dimension 3, the patient has significant co-morbidity (score 3) considering her recent substance use of alcohol and cocaine with clearly detrimental effects on her mood symptoms, but which has been temporarily arrested through the highly structured treatment setting. The patient was using so heavily prior to treatment that she was prostituting to get access to drugs and alcohol. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The records document that the patient has difficulty avoiding exposure to active substance users and has continued substance and alcohol cravings while in RTC. For dimension 4B, the patients recovery environment has provided limited support (score 3) given the patients isolation from friends since they all use substances and alcohol, and the patients reliance on her mother and aunt for support. A few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4) since the patient has been hospitalized several times, in RTC once before and most recently in PHP. The patient has been unable to maintain gains made outside of a structured treatment setting. Overall, attempts to maintain whatever gains that can be attained in intensive treatment have limited success, even for limited time periods or in structured settings. For dimension 6, the patient has shown limited engagement and recovery (score 3). The provider noted that the patient appears motivated in RTC but with some ambivalence about her recovery and limited ability to accept responsibility for her recovery. 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 supports medically monitored residence-based services. Additionally, in terms of length of stay, the patient meets criteria for level 5B: moderate intensity intermediate stay residential treatment program up to 60 days 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 and 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 adult psychiatric RTC services rendered at A Mission for Michael from 2/28/22 forward were and are medically necessary for 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.