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 adult mental health 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. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to reporting extreme distress leading up to her admission to the RTC, a past suicide attempt, and some evidence of self-neglect with poor hygiene. The patient did not endorse active suicidal or homicidal ideation.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to the patients inability to work due to the severity of her symptoms. The patient reported isolating, with conflictual relationships with much of her family. Due to recent manic symptoms, the patient was jailed for five months following impulsive and aggressive behaviors. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to the presence of hypertension and erythema nodosum that are treated with steroids during flares. Given the patients recent bipolar mania, steroids increase the risk of this patients psychiatric decompensation. The patient has also struggled with alcohol use disorder. In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has a highly stressful environment due to a severe disruption in life circumstances, recently being released following five months in jail due to violating a court order as a result of a manic episode. With regard to level of support of the recovery environment, the records support a score of 4 as the patient has limited support, isolating herself and with conflictual relationship with her children. The patient reports her only support being her husband.   In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, as she has been hospitalized several times and undergone residential and inpatient treatment without any sustained benefit outside of a structured setting. With regard to treatment acceptance and engagement, the records support a score of 3. The patient is noted to have limited confidence in her ability to change despite her intentions to do so. Thus, the patient has a total score of 26. The records support a 4 in terms of functional status and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the functional status and comorbidity noted, the patient meets LOCUS 5b extended stay criteria. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, adult mental health RTC services were and are medically necessary for the 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.