Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 50-year-old male with a history of bipolar I disorder, current or most recent episode 
manic with psychotic features, and alcohol use disorder, severe, in early remission. The patient 
was admitted to the residential treatment center (RTC) on 12/13/22. The patient has requested 
reimbursement for adult mental health RTC services provided from 12/20/22 through 1/3/23. The 
Health Insurer has denied the services at issue as not medically necessary for the treatment of the 
patients medical condition. This denial is the subject of this appeal and determination. The 
physician reviewer found that 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, this patient did not meet the criteria for RTC services provided from 12/20/22 through 
1/3/23. For dimension 1, the patient was at low risk of harm (score 2) due to no active suicidal 
ideation but extreme distress and/or a history of suicidal behavior exists. Per the history, the patient 
experienced  an exacerbation of mood  and psychotic symptoms after  abruptly discontinuing 
Lamictal, gabapentin, and Antabuse. However, the patients objective mental status examination 
was not consistent with the history of the present illness. The patient denied suicidal and homicidal 
ideation, and there was no obvious overt sign of psychosis during the interview. For dimension 2, 
the patient demonstrated mild functional impairment (score 2) given his recent experience of some 
minor disruptions in aspects of self-care or usual activities. There was a lack of evidence that the 
patient was gravely disabled without supervision 24 hours per day to develop skills necessary for 
daily living. The group notes describe the patient as well-groomed, performing activities of daily 
living, and sleeping well. For dimension 3, the patient has significant comorbidities (score 3). The 
records document recent substance use which has had clearly detrimental effects on the presenting 
disorder but which has been temporarily arrested through the use of a highly structured or protected 
setting or through other external means. The patient has a history of ADHD, bipolar disorder, and 
alcohol abuse. (e) For dimension 4A, the patients recovery environment was mildly stressful 
(score 2) considering the patients potential for exposure to alcohol and or drug use existed. The 
records indicate that the patient has a place to stay and was previously sober in that living 
environment. For dimension 4B, the patients recovery environment provided limited support 
(score 3). The records document that a few supportive resources existed in the current environment 
and may have been capable of providing some help if needed. The patient has a place to stay, has 
been sober before in that living environment, and had minimal social stressors to increase his 
relapse risk. For dimension 5, the patient has exhibited a significant response to treatment and 
recovery management (score 2). The provider noted that recovery has been managed for moderate 
periods of time with limited support or structure. Previous outpatient treatment has been successful 
for the patient, he has maintained periods of sobriety in the past, and this relapse could have been 
managed in an outpatient setting. For dimension 6, the patient has shown positive engagement and 
recovery (score 2) since he demonstrated significant understanding and acceptance of his illness 
and its effect on his function. The patient was engaged in treatment at the facility and shared insight 
into his alcohol use. The provider noted that the patient participated in all therapy sessions and 
was motivated to make changes to become abstinent. The patient has been sober in treatment at a 
lower level of care in the past.  These findings give the patient a composite score of 16, which is  consistent with Level 2 low-intensity community-based services. Therefore, the adult mental 
health RTC services provided from 12/20/22 through 1/3/23 were not medically necessary for the 
treatment of the patients condition.