Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 22-year-old female with a history of persistent depressive disorder, social anxiety 
disorder, emerging post-traumatic stress disorder (PTSD), and emerging borderline personality 
disordered traits.  The patient has requested reimbursement for the adult mental health RTC 
services provided from 6/1/21 through 9/13/21. The Health Insurer has denied the services at issue 
as not medically necessary. This denial is the subject of this appeal and determination. The physician 
reviewer  found  that  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 met the criteria for RTC services provided from 6/1/21 through 9/13/21. 
For dimension 1, the patient was at serious risk of harm (score 4) due to continued suicidal ideation 
and  self-injurious  behavior throughout  her  RTC  stay.  The  patients  behavior  culminated  in 
discharge from RTC when she was hospitalized with active suicidal ideation, walking along the 
side of the highway with thoughts of jumping in traffic, and continued self-injurious behavior. 
Current suicidal or homicidal ideation with expressed intentions and/or past history of carrying out 
such behavior but without means for carrying out the behavior. For dimension 2, the patient 
demonstrated serious functional impairment (score 4) since she has been unable to attend school 
or work due to severe symptoms. The patient had consistently conflictual relations with both staff 
and other patients, became dysregulated even while in treatment, and acted with impulsive and 
aggressive behaviors. Overall, the patient showed a serious decrease in the quality of interpersonal 
interactions with consistently conflictual or otherwise disrupted relations with others, which may 
include impulsive, aggressive or abusive behaviors. For dimension 3, the patient has significant 
co-morbidities (score 3) considering her significant substance use prior to entering RTC. The 
patients learning disorder made it difficult for her to learn new skills while in treatment. The 
patient  also  was  found  to  have  fecal  impaction  and  constipation  when  she  complained  of 
abdominal pain toward the end of her RTC admission. The records document ongoing or episodic 
substance use occurring despite negative consequences with significant or potentially significant 
negative impact on the course of any co-occurring psychiatric disorder. For dimension 4A, the 
patients recovery environment was moderately stressful (score 3) given the patients significant 
discord and difficulties in all of her relationships due to her inability to communicate effectively 
and with conflict. There is evidence of significant discord or difficulties in family or other 
important relationships or alienation from social interaction. For dimension 4B, the patients 
recovery environment provided limited support (score 3). The records indicate that the patient 
relied heavily on her parents for support despite her conflictual exchanges with them. A few 
supportive resources exist in current environment and may be capable of providing some help if 
needed. For dimension 5, the patient showed poor response to treatment and recovery management 
(score 4). The provider noted that the patient was hospitalized psychiatrically leading up to her 
RTC stay, attempted treatment at intensive outpatient program (IOP) and in various outpatient 
treatment settings. Even within RTC setting, the patient was unable to achieve remission of 
symptoms. Thus, 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 exhibited minimal engagement and recovery (score 4). The 
records noted that the patient showed great difficulty accepting any responsibility for recovery and 
had consistently conflictual relationships with treatment providers. Overall, the patient did not 
accept any responsibility for recovery or felt powerless to do so. These findings give the patient a 
composite score of 25, which is consistent with medically monitored residence-based services or 
RTC. Additionally, the patient scores of 4 in risk of harm and functional status support placement 
in RTC. Additionally, in terms of length of stay, the patient meets criteria for level 5B moderate 
intensity  intermediate  stay  residential  treatment  programs  due  to  significant  disturbance  in 
interpersonal skills as well as serious impairment in expected role functioning at home, school and 
work. For these reasons, the adult mental health RTC services provided from 6/1/21 through 
9/13/21 were medically necessary for treatment of this patient.