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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for admission to residential treatment center (RTC) level of care. 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 meets the criteria for RTC services.For dimension 1, the patient has been at serious risk of harm (score 4). The records document that the patient has no past suicide attempts but repeatedly endorses passive suicidal ideation without intent or plan recently due to severe distress. The patient reported that she has been taking Ativan on a regular basis and occasionally combining it with alcohol. Additionally, the patient has demonstrated a recent pattern of excessive substance use resulting in loss of self-control and clearly harmful behaviors with no demonstrated ability to abstain from use despite clinical support. For dimension 2, the patient has shown moderate functional impairment (score 3) due to inability to work secondary to her symptoms and substance abuse. The patients parents have evicted her from their house due to substance use. The patient has experienced consistently conflictual relations with her main supports. There is evidence of significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has major co-morbidity (score 4). The provider noted that the patients substance use has had clearly detrimental effects on her psychiatric symptoms, with patients anxiety and depression escalating, but patient is unable to control the substance use. There is report of uncontrolled substance use occurring at a level that poses a serious threat to health if unchanged, and/or which poses a serious barrier to recovery from any co-occurring psychiatric disorder. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The records indicate that the patient has easy exposure and access to substances. Additionally, the patient is living with friends who have substance use issues. In addition, the patient is unable to return home due to substance use. The patient has difficulty avoiding exposure to active users and other pressure to partake in alcohol or drug use. For dimension 4B, the patients recovery environment provides limited support (score 3) due to the presence of a few supportive resources. The patient is noted to have a conflictual relationship with her parents. A few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4). The provider charted that the patient has completed detoxification and several admissions to IOP in the past year without complete remission of symptoms. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 6, the patient has exhibited minimal engagement and recovery (score 4). The provider charted that the patient has some variability and hesitation in accepting her illness, particularly her substance disorder. The patient does not accept responsibility for her recovery or feels powerless to do so. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services. In addition, the patients score of 4 in risk of harm supports placement in RTC. Moreover, in terms of length of stay, the patient meets criteria for level 5B moderate intensity intermediate stay residential treatment program for up to 60 days due to her ongoing difficulties with life circumstances exceeding her ability to cope and serious impairment in expected role functioning at home, work or school. Furthermore, the RTC services 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. Therefore, the requested admission to RTC level of care is medically necessary for 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.