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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective 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. Applying the LOCUS framework, the patient meets the criteria for RTC services.For dimension 1, the patient has been at moderate risk of harm (score 3). The records document that the patient denies any suicidal ideation or homicidal ideation. The provider noted that the patient also denies all other symptoms and she lacks insight. The patient has negative self-talk and has been neglecting her self-care with a decrease in her ability to care for herself. The records document some evidence of self-neglect and/or decrease in ability to care for oneself in current environment. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given her great difficulty functioning normally with significant withdrawal and avoidance of social interactions and with recently more conflictual interactions with her main supports. The patient has unable to work due to her symptoms and is having difficulty caring for her needs. There is documentation of significant withdrawal and avoidance of almost all social interaction and inability to perform close to usual standards in school, work, parenting, or other obligations and these responsibilities may be completely neglected on a frequent basis or for an extended period of time.  For dimension 3, the patient has significant comorbidities (score 3). The provider noted that the patient has continued to use cannabis episodically despite heightened depression and anxiety. 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 has been moderately stressful (score 3) due to isolation from others, inability to work due to her symptoms, financial dependence on her mother, and her perception of the pressure to perform surpasses her ability to meet obligations. The records support perception that pressure to perform surpasses ability to meet obligations in a timely or adequate manner. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider reported that the patient depends heavily on her mother and boyfriend, although the patient has experienced conflicts with them recently. 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) since the patients previous treatment has not achieved complete remission of symptoms. The patient continues to have significant mood episodes and inability to pursue school or maintain a job because of these symptoms. The patient has engaged in IOP, PHP and inpatient levels of care without sustained remission of symptoms. There is evidence that 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 limited engagement and recovery (score 3). The records document that the patient has significant mood symptoms, racing thoughts, and anxiety, which limit her ability to fully engage in treatment. However, the provider noted that the patient has shown some motivation for treatment. The patient has limited desire or lacks confidence to change despite intentions to do so. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services or RTC. Additionally, in terms of length of stay, the patient meets criteria for level 5B moderate intensity intermediate stay residential treatment programs with length of stay up to 60 days due to significant disturbance in interpersonal skills as well as serious impairment in expected role functioning in work, school and home. Moreover, the RTC services were and 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. All told, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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.