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. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to endorsing ongoing passive suicidal ideation, a history of numerous suicide attempts, and ongoing substance use resulting in the loss of self-control, including being jailed recently following an altercation. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient has had consistently conflictual interpersonal interactions with others, including in abusive and aggressive behavior while in treatment, which has impeded her getting treatment. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to recent opioid use with exacerbating effects on her mood and behavior. The records note that a history of seizures while in a prior RTC, thought to be non-epileptiform. In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has a highly stressful environment due to continued easy access to opioids. The patient was recently jailed following an altercation and reported that she had lost her housing. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has limited supportive resources due to a conflictual relationship with her mother and with her boyfriend. The patient was recently in an altercation with her boyfriend, leading to her arrest. The patient has some support from sponsor.  In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recover management  as she has a history of attempting RTC treatment, but  with administrative discharges for seizures and abusive behaviors. The records noted that the patient was able to maintain some sobriety while in day treatment but relapsed with any stressors.With regard to treatment acceptance and engagement, the records support a score of 4. The patient has difficulty accepting responsibility for recovery and relates quite poorly to treatment providers. Thus, the patient has a total score of 26. The records support a 4 in terms of functional status and risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets LOCUS 5b extended stay criteria. In this patients case, RTC level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, RTC services are medically necessary for the 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.