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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 30 days of residential treatment center (RTC) services, including two days a week of one hour sessions of eye movement desensitization and reprocessing (EMDR) therapy, or in the alternative 30 days of RTC services without EMDR therapy. 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 does not meet the criteria for 30 days of RTC services. For dimension 1, the patient has been at significant risk of harm (score 3) due to her comments that she does not feel safe at home in the absence of 24-hour monitoring. The patient has a remote history of overdose about 10 years prior. There is no active suicidal ideation, but extreme distress and a history of suicidal behavior. For dimension 2, the patient has demonstrated mild functional impairment (score 2). The patient reports that she has been able to work full time as a care companion for patients with substance abuse issues. She indicated that she is able to administer medications, assist with ADLs, and provide transportation for these patients. The patient complains of excessive sleep on the weekends and a lack of motivation. There is some evidence of minor failures of function in any of several areas of living. These periodic or momentary failures are time limited. For dimension 3, the patient has minor comorbidities (score 2) given her diagnoses of PCOS and sciatica. The self-limiting medical conditions present are not immediately threatening or debilitating and that have no impact on the presenting condition and are not affected by it. For dimension 4A, the patients recovery environment is mildly stressful (score 2) considering her conflict with her roommates. There is no documentation of significant discord, her housing appears stable, and there are no major losses or transitions. There is minor interpersonal loss or conflict. For dimension 4B, the patients recovery environment is supportive (score 2) due to her family and friends who continue to support her treatment. Her aunt offered to help distribute her medications, and she feels comfortable asking her family for financial support. Family/primary caretakers are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. For dimension 5, the patient has exhibited moderate or equivocal resiliency and response to treatment (score 3). The records document that the patient has not achieved complete remission of symptoms. Per the assessment last month, patients depression is mild, and the patient reported that her medications have been optimized. The patient indicated that she is just getting started in terms of her trauma recovery. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms. For dimension 6, the patient has been constructive in treatment (score 2). The provider noted that the patient has been actively engaged in treatment. She actively sought care and has tried to remain in treatment. She told multiple providers that she wants to continue to work on improving and continuing therapy. She accepted her role in recovery and is willing to change. The patient has been able to develop a trusting, positive relationship with clinicians and other care providers. This gives the patient a composite score of 16, which is consistent with low intensity community-based services. Per LOCUS, the patients score of 3 on risk of harm supports high intensity community-based services. The patient could benefit from EMDR therapy. She reported on 8/24/20 numerous symptoms of PTSD including intrusive thoughts, avoidance behaviors, nightmares, insomnia, and irritability. EMDR is considered first-line therapy for PTSD and is indicated in this case. However, EMDR can be provided in the outpatient setting. Given these findings, the requested 30 days of RTC services, including two days a week of one hour sessions of EMDR therapy, or in the alternative 30 days of RTC services without EMDR therapy, is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.