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

Findings:  The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for 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. Applying the LOCUS framework, the patient meets the criteria for the RTC services.For dimension 1, the patient has been at moderate risk of harm (score 3). The records document that the patient presented to RTC with significant suicidal ideation with a plan to drive off the road but without intent and no history of suicide attempts. In addition, the patient has some evidence of self-neglect and decreased ability to care for oneself. There is documentation of significant current suicidal ideation without intent or conscious plan and without past history. Also noted was some evidence of self-neglect and decrease in ability to care for oneself in current environment. For dimension 2, the patient has demonstrated serious functional impairment (score 4). The provider described the patient as conflictual with labile behavior in interpersonal interactions in the RTC. The patient is unemployed and relying on parents. The patient reported eating more with substantial weight gain over the last three months and sleeping 12 hours per night due to symptoms of depression. There is evidence of serious disturbances in physical functioning such as weight change, disrupted sleep, and fatigue that threaten physical well-being. For dimension 3, the patient has significant comorbidities (score 3) due to escalating substance use with legal consequences as well as psychotic and mood symptoms. The records indicate that the patients recent substance use, which has had clearly detrimental effects on the presenting disorder, has been temporarily arrested through use of highly structured or protected setting. For dimension 4A, the patients recovery environment is moderately stressful (score 3) since the patient has quit a job and has recently experienced legal problems related to substance use disorder. The patient has a perception that the pressure to perform surpasses ability to meet obligations in a timely or adequate manner. For dimension 4B, the patients recovery environment provides limited support (score 3) since the patient relies on parents for support and has isolated from peers. The patients ex-boyfriend has been described as abusive. The records indicate that few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3). The records indicate that the patient has been treated in several substance use programs, which have not achieved remission of substance use issues. The patient has also continued to struggle with symptoms of depression over the last six years. The records document that previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has shown minimal engagement and recovery (score 4) since the patient has been described as irritable in treatment and difficult to redirect toward the use of coping skills. The patient does not accept any responsibility for recovery or feels powerless to do so. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. Per LOCUS, the patients scores of 4 for functional status also support treatment at Level 5 medically monitored residence-based services level of care. Additionally, in terms of length of treatment in a medically monitored residence-based program, the patient meets criteria for intermediate stay, level 5B, with expected length of stay not exceeding 60 days due to continued difficulty with interpersonal skills and interactions and ambivalence regarding substance use cessation, currently arrested while in a highly structured treatment setting but previously negatively impacting mental health. Moreover, the RTC services 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 are not primarily for the convenience of the patient or provider. For these reasons, the RTC 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.