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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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 met the criteria for RTC services.For dimension 1, the patient was at moderate risk of harm (score 3) due to fluctuating reports of suicidal ideation and self-harm urges throughout RTC admission, particularly with worsened eating disorder symptoms. The patient also has a documented history of self-harm by cutting. The records document significant suicidal ideation without intent or conscious plan and without past history. For dimension 2, the patient demonstrated serious functional impairment (score 4) given the patients inability to attend school or work due to severe symptoms. The patient was isolative with significant withdrawal and avoidance of almost all social interactions. For dimension 3, the patient has significant co-morbidity (score 3) given her persistent tachycardia and hypotension throughout much of her RTC treatment. The patient was previously hospitalized medically for dehydration. The patient is noted to have cystic acne, which worsens her depression and anorexia. The patients eating disorder has also disrupted her menstrual cycle. Medical conditions exist, which may require significant monitoring, and which may have been created or adversely affected by the existence of the presenting disorder. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The records document that the patient was isolated to home. The patient reportedly competes with her sister to lose weight and she identifies both her parents to have eating disordered behaviors. The patients perception that there is pressure for her to perform surpassed her ability to meet these obligations in a timely or adequate manner. For dimension 4B, the patients recovery environment provided limited support (score 3). The patient was isolated from most social supports and had conflictual relationships with her parents and sister. A few supportive resources existed in current environment and may have been capable of providing some help if needed. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4). The provider noted that the patient was able to restore her weight for a couple months in 2020 but only in the context of intensive treatment. Outside of intensive treatment, the patients mood and eating disorder symptoms quickly spiraled again. Thus, attempts to maintain whatever gains that could be attained in intensive treatment have limited success, even for limited time periods or in structured settings. For dimension 6, the patient showed limited engagement and recovery (score 3) given her anxiety and inability to engage in treatment or accept responsibility for her own recovery. The patient often blamed her family influences for her current symptoms. She also had repeated conflict with the providers treatment plans. The patient showed limited ability to accept responsibility for recovery. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services or RTC. Additionally, the patient scored a 4 in functional status, which also supports medically monitored residence-based services. In terms of length of stay, the patient met criteria for level 5B moderate intensity intermediate stay residential treatment programs due to significant disturbance in interpersonal skills as well as serious impairment in expected role functioning at home, school, and work. Moreover, the RTC services were 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, the psychiatric RTC services were medically necessary for treatment of this patient based on the provided documentation. 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.