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. Applying the LOCUS framework, the patient meets the criteria for RTC level of care. For dimension 1, the patient is at serious risk of harm (score 4) due to a history of aborted suicide attempt as well as continued passive suicidal ideation without current intent or plan. This supports current suicidal or homicidal ideation with expressed intentions and/or past history of carrying out such behavior but without means for carrying out the behavior, or with some expressed inability or aversion to doing so. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) since the patient stopped attending college due to current symptoms. The patient is working but is struggling with this as well. The patient has shown 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 comorbidities (score 4) with ongoing tachycardia, abdominal pain, and chest pain, all related to her eating disorder. She has required treatment in the emergency department on several occasions for these complaints and requires weekly follow-up with a provider for close monitoring. Medical conditions exist which are clearly made worse by the existence of the presenting disorder. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The records document that the patient has a conflictual relationship with parents at home. The patient has a great deal of stress at work and has been unable to fulfill the responsibility of succeeding in college. This indicates significant transition causing disruption in life circumstances such as job loss, legal difficulties or change of residence. For dimension 4B, the patients recovery environment provides limited support (score 3) given her troubled relationship with parents at home, and plans to move in with a friend, although this has not materialized. The patient has experienced difficulties accessing support when it is available. Resources may be only partially utilized even when available. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4) due to inability to maintain any gains attained in intensive treatment outside of the structured setting. The patient has been in treatment consistently for the last two years with limited recovery overall. Attempts to maintain whatever gains that can be attained in intensive treatment have limited success, even for limited time periods or in structured settings. For dimension 6, the patient has exhibited limited engagement and recovery (score 3). The provider noted that the patient is partially motivated for treatment with some variability. The patient relates to the treatment team with some difficulty. The patient relates to treatment with some difficulty and establishes few, if any, trusting relationships. These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services or RTC. Moreover, the requested 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. For these reasons, the requested RTC services are 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.