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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for community-based adult 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. With regard to risk of harm, the records support a score of 2. The patient has some risk of harm, due to intermittent passive suicidal ideation without plan or intent and without a past history of known suicide attempts. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient has been quite isolated through the pandemic and reported often staying in bed due to depressive symptoms. The patient reported ongoing deficits in relationships with very limited social interaction and trouble engaging socially.  With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity as she is overweight and is on psychotropic medications, including Zyprexa, that cause additional weight gain and increase her chances for cardiovascular morbidity. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient has a mildly stressful environment due to living in an independent supported living environment, sharing a room with three roommates. The patient reports being much more socially withdrawn due to the pandemic.With regard to level of support of the recovery environment, the records support a score of 3 as the patient has very few actual supports as she does not have family close by and reported not having many friends. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment as she has been able to achieve moderate recovery from psychotic illness, but this recovery is only maintained with strong professional support. With regard to treatment acceptance and engagement, the records support a score of 2. The patient seeks out and benefits from engagement with recovery services. Thus, the patient has a total score of 18. In this case, the recommended level of care is high intensity community-based services. Therefore, community-based adult services are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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.