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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for any or all of the residential treatment center (RTC) level of care provided. Findings:  The physician reviewer found that At issue in this case is whether the any or all of the RTC level of care provided was medically necessary to treat the enrollees medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.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 history of suicidal ideation and self-injury, with recent urges to self-harm. She has no current active suicidal ideation or homicidal ideation, but she continues to have trouble caring for herself in her home environment, putting herself in danger, and with suicidal ideation returning with any stress.In terms of function, the records support a score of 4. The patient has been unable to attend school due to her eating disorder, isolates herself and does not engage very much with others due to her active symptoms. Her family relations are significantly conflictual. The patient has been unable to maintain weight outside of RTC and has poor sleep and concentration.With regard to comorbidity, the records support a score of 3. The patient was anemic on admission to RTC and also had symptomatic orthostatic hypotension throughout her RTC admission, both likely due to her poor nutritional intake due to her active eating disorder.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had significant discord in her family, having trouble accessing them as supports. The patients family has difficulty supporting the patients eating disorder recovery at home.With regard to level of support of the recovery environment, the records support a score of 4 due to superficial support from family with whom she lives, but they themselves suffer from eating disorders and have trouble fully supporting the patient. She has great difficulty tapping into any supports from family and friends and has been significantly isolated through the pandemic.In terms of treatment and recovery history, the records support a score of 4. The patient has had a very poor response to treatment in the past, despite having been in eating disorder treatment at all levels of care. Shes not been able to maintain gains made outside of the structured treatment settings.With regard to engagement, the records support a score of 2. The patient is positively engaged and motivated for treatment.These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services or RTC. In terms of length of treatment required, the patient has had some suicidal ideation with history related to self-harm and suicidality, but without any attempts. She has also been unable to function in work or school with ongoing difficulties with life circumstances exceeding her ability to cope and enter the recovery process. Thus, she meets criteria for level 5B or short-term residential rehabilitation, with length of stay not to exceed 60 days. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, RTC level of care provided was medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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.