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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services using the Plate by Plate approach. Findings:  The physician reviewer found that 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 LOCUS, this patient met the criteria for PHP services. For dimension 1, the patient was at moderate risk of harm (score 3) due to her inability to adequately care for herself. The provider noted that the patient was unable to adequately nourish herself due to her eating disorder. She was admitted to medical inpatient unit for bradycardia and hypotension due to malnutrition. There was some evidence of self-neglect and decrease in ability to care for oneself in current environment. For dimension 2, the patient demonstrated severe functional impairment (score 5). The provider noted that the patient recently took a medical leave from college due to loss of 17 pounds during her first semester. At the recommendation of her eating disorder specialist, she was instructed to go on leave from school in order to be treated for her malnutrition and eating disorder after a medical admission for bradycardia and hypotension. The patient showed complete inability to maintain any aspect of her basic needs including food intake with associated impairment in physical status. For dimension 3, the patients primary condition was anorexia nervosa (score 3) with significant comorbidities including OCD and vomiting. The patients fear of germs caused her additional anxiety about her eating disorder. Significant psychiatric symptoms and signs were present which were themselves somewhat debilitating. For dimension 4A, the patients recovery environment was moderately stressful (score 3) as she required a leave from college and moved back home with her family in order to recover from her eating disorder. The patient underwent a significant transition causing disruption in life circumstances. For dimension 4B, the patients recovery environment was highly supportive (score 1) since her parents were active participants in the patients treatment plan. The provider noted that the patients parents fully participated in treatment and actively sought to provide the patient with the appropriate services. The patient had plentiful sources of support with ample time and interest to provide for both material and emotional needs in most circumstances. For dimension 5, the patient exhibited moderate or equivocal response to treatment and recovery management (score 3) due to her periods of doing relatively better with her eating disorder but then being unable to maintain the progress when in unstructured environment. The records document that the patient gained enough weight so that she could attend college, but then she lost 17 pounds during her first semester in college. This supports an unclear response to treatment and ability to maintain a significant recovery. For dimension 6, the patient showed limited engagement and recovery (score 3) given her continuous treatment for her eating disorder for at least three years. She was agreeable to participating in treatment but had difficulty in changing problematic behaviors and sustaining gains made during structured treatment. She had some insight into her eating disorder but demonstrated a limited desire to make changes despite stated intentions to do so. These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services, such as PHP. The patient was overwhelmed by her eating disorder, as evidenced by a 17-pound weight loss within her first few months in college. The Plate by Plate approach was indicated to help the patient rebuild a healthy relationship with food. Therefore, the PHP level of care, utilizing the Plate by Plate approach provided was 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.