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 partial hospitalization program (PHP) 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 criteria for PHP services. For dimension 1, the patient has been at moderate risk of harm (score 3) due to a history of self-injurious behavior and chronic passive suicidal ideation. The provider noted that the patient has demonstrated chronic impulsive self-injurious behaviors without current suicidal ideation. The patient also has a history of excessive substance use resulting in overdose that required treatment with Narcan. The records document no active suicidal ideation, but extreme distress and/or a history of suicidal behavior exists. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) given her significant deterioration in her ability to fulfill responsibilities leading up to admission. Although the patients symptoms have been in better control with intensive treatment, she continues to struggle, and her recent gains have been achieved while participating in treatment in a structured setting. There is evidence that recent gains and/or stabilization in function have been achieved while participating in treatment in a structured and/or protected setting. For dimension 3, the patient has significant comorbidities (score 3) since she continues to struggle with ambivalence about her substance use. The records document that the patients recent substance use has had clearly detrimental effects on the patients presenting disorder and symptoms but has been temporarily arrested through use of a highly structured or protected setting or other external means. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) due to loss of her apartment prior to treatment. The provider noted that after discharge the patient will require a safer housing situation. The provider reported that the patient has easy access to substances in her environment. There is documentation of significant transition causing disruption in life circumstances such as job loss, legal difficulties, or change of residence. For dimension 4B, the patients recovery environment is supportive (score 2). The provider noted that the patient indicated that she is more able to rely on her mother now that she is invested in treatment. The records indicate that some elements of the support system are willing and able to participate in treatment of requested to do so and have capacity to effect needed changes. For dimension 5, the patient has shown moderate or equivocal response to treatment and recovery management (score 3). The patient has been treated in higher levels of care. The patient has been able to maintain sobriety and psychiatric stability only within highly structured treatment settings. Partial recovery was maintained for short periods of time outside of those settings. Thus, at least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings. For dimension 6, the patient has exhibited limited engagement and recovery (score 3) considering her increased engagement in treatment though with some variability and ambivalence at times. There is report of some variability, hesitation or uncertainty in acceptance or understanding of illness and disability. These findings give the patient a composite score of 20, which is consistent with medically monitored community-based services or PHP. Moreover, the PHP 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. For these reasons, PHP 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.