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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center 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. For dimension 1- risk of harm. This dimension assesses potential for harm to self or others. Per the clinical record for the time period considered, the patient was not suicidal or homicidal. The patient was still susceptible to eating related self-harm behaviors, however. [Score 3  moderate]For dimension 2  Function. This dimensions assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. This patient was noted to be interactive with staff and others, though she did continue to have a problematic relationship with her mother. [Score 2  mild]For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. This patient had psychiatric disorders (anorexia and depression) that had significant concomitant medical consequences including continued low BMI and abnormal laboratory testing that required close monitoring. [Score 4- major co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient had a mildly stressful environment with some ongoing interpersonal conflict with her mother. [Score 2 -mild] For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient had a supportive environment, as she lived with her father, who was willing to participate in treatment, but he worked long hours. While the patients support sources may not have been abundant, she did have a parent who was willing to provide significant support in time of need. [Score 2- mild]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient had failed intensive outpatient therapy as well as partial hospitalization, which reflected a poor response to treatment and recovery management. [Score 4- poor response]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The submitted records reflect that the patient expressed an understanding of progress that she had made and indicated a wish to continue care at the partial hospitalization level of care. [Score 2- positive engagement]These findings give the patient a composite score of 19, which is consistent with Level 3 (High Intensity Community Based Services). Accordingly, residential treatment center services at issue were not medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients condition. Therefore, the Health Plans denial should be upheld.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.