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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the 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. Based on the LOCUS guidelines, the patient did not meet the criteria for RTC level of care services. The patient demonstrated some risk of harm (score 2) given her passive suicidal ideation. The records do not document any active urges or intent, or self-injurious behavior. She did endorse passive suicidal ideation throughout her college years as well as during her RTC, but never acted on these urges or made any suicide attempts. She never exhibited any self-injurious behavior. The patients functional status was moderately impaired (score 2) as she was socially isolated among her peers. However, the patient maintained a relationship with her parents, who traveled across the country to attend family meetings. The patient presented with minor comorbidity (score 2) given her diagnosis of Celiac disease. There was no mention of any flare-ups or medical concerns during her stay. She had no substance use disorder and only drank alcohol on occasion. She showed some food binging behaviors that occurred about twice a month but did not affect her weight or metabolic status. She had some compulsive behaviors with OCD, but these symptoms did not occupy a significant amount of time such that her functioning was impaired. She had no substance abuse problems. She did not have any psychosis or divorce from reality. The patients recovery environment was mildly stressful (score 2). The records noted that she graduated from college and was living at home with her family, which was supportive of her during the RTC admission. Transition to post-college life represented a significant change for the patient. The patient was in the RTC for over one year with limited overall response (score 4). The provider noted that by discharge, the patient demonstrated some improvement in her mood and functioning. The patient was constructive with her treatment (score 2) and was described as positively engaged in her therapy. The chart documents that she initiated and arranged for her own admission to the RTC. She was highly motivated to improve her mood and social anxiety, as well as learn to formulate trusting relationships. This gives the patient a composite score of 14, which is consistent with low intensity community based services. The patient was a candidate for treatment in the outpatient setting with medication management and did not meet the criteria for RTC services. All told, the RTC services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.