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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for psychiatric 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, this patient met the criteria for the RTC services.For dimension 1, the patient was at moderate risk of harm (score 3) due to the patients reports of suicidal ideation for the last four years without a history of suicide attempts. This supports significant current suicidal ideation without intent or conscious plan and without past history. For dimension 2, the patient demonstrated serious functional impairment (score 4) due to his inability to maintain personal hygiene and poor school performance. The patient also had disrupted sleep. He isolated himself, and he avoided social interaction. Significant withdrawal and avoidance of almost all social interaction. For dimension 3, the patient has no reported comorbidities (score 1). The patient has multiple psychiatric problems but no medical or substance use problems. No evidence of medical illness, substance use disorders, or psychiatric disturbances apart from the presenting disorder. For dimension 4A, the patients recovery environment was highly stressful (score 4). The records document that the patient perceived overwhelming demands to meet immediate obligations, identity issues, and conflictual family relationships. Overwhelming demands to meet immediate obligations was perceived. For dimension 4B, the patients recovery environment provided limited support (score 3) as noted by the providers. The patient did not utilize resources available to him and he isolated himself. Usual sources of support may be somewhat ambivalent, alienated, difficult to access, or have limited resources they are willing or able to offer when needed. For dimension 5, the patient exhibited negligible response to treatment (score 5). The patient was in intensive outpatient treatment for nine months, with worsening of symptoms in terms of depression, anxiety, and suicidal ideation. Past or current response to treatment has been quite minimal, even with intensive medically managed exposure in highly structured settings for extended periods of time. For dimension 6, the patient demonstrated limited engagement and recovery (score 3), given his difficulty in accepting responsibility and consequences of his actions. The patient had trouble owning his role in treatment and trouble building trusting relationships. This suggests that the patient had limited ability to accept responsibility for recovery. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. Per LOCUS, the patients scores of 4 for functional status also supports treatment at Level 5 medically monitored residence-based services level of care. Additionally, in terms of length of treatment in a medically monitored residence-based services, the patient meets criteria for intermediate stay medically monitored residence-based services with treatment up to 60 days, given patients suicidal ideation, great difficulty with interpersonal relationships, inability to function in school, and prior failure of treatment at IOP level of care. For these reasons, the RTC services were medically necessary for 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.