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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. Findings:  The physician reviewer found that he 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 PHP services from admission and onward.ith regard to risk of harm, the records support a score of 4. The patient had a serious suicide attempt just last month in which she overdosed on 30 Klonopin tablets. She again had suicidal ideation (SI) ten days later and was admitted psychiatrically. The patient continues to fear that SI will return.In terms of function, the records support a score of 3. The patient has not been able to work due to her anxiety despite attempts to return to work and has been conflicted in her most significant family relationships.With regard to comorbidity, the records support a score of 3. The patient has had hip surgery and a hysterectomy in the last year and continues to recover. The patient has also had issues with managing her blood pressure and headaches recently, which are compounded by her psychiatric distress.In terms of level of stress of the recovery environment, the records support a score of 3. The patient started a new job last year, which she is conflicted about and which causes her anxiety. The patient is very close with her brother and his family, and her brother is going through a divorce resulting in a family transition.With regard to level of support of the recovery environment, the records support a score of 2. The patient is able to rely on her husband although her relationships with her children and the rest of her family are often times conflicted.In terms of treatment and recovery history, the records support a score of 4. The patient has been in outpatient treatment for the last 20 years and recently was admitted, but she continues to struggle with significant psychiatric symptoms and intermittent SI.With regard to engagement, the records support a score of 3. The patient has had tenuous engagement due to her frustration with scheduling psychiatric services.These findings give the patient a composite score of 22, which is consistent with medically monitored community-based services or PHP. For these reasons, PHP services from admission onward were and are medically necessary for treatment of the patients medical condition. The requested PHP services from admission onward were and are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, PHP services from admission onward were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The PHP services from admission onward were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, partial hospitalization program (PHP) services fromadmission onward were and are medically necessary for treatment of the patients medical condition.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.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.