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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services for a minimum of 30 days. 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 RTC services for a minimum of 30 days.For dimension 1, the patient has been at moderate risk of harm (score 3) due to the patients inability to perform activities of daily living, behaviors of self-neglect, and decreased ability to care for himself. The patient denies any suicidal ideation. The records document 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 The records document that the patient is significantly withdrawn and avoids almost all social interactions with continued struggles with his activities of daily living. The patient has shown significant withdrawal and avoidance of almost all social interaction. For dimension 3, the patient has significant co-morbidity (score 3) given the reports of significant self-neglect and difficulty performing activities of daily living. Given the patients severe degree of failure to thrive and dehydration on presentation in 2021, the patient continues to be at risk for medical decompensation. Additionally, the patient has a history of hypertension, diabetes mellitus, peptic ulcer disease, and he struggles with poor appetite and weight loss. Medical conditions exist or have potential to develop (such as diabetes or a mild physiologic withdrawal syndrome), which may require significant medical monitoring. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) since the patient was forced to leave his lifelong home in 2021 when he was found to be living in a hoarding situation. The patient is now in an assisted living facility, but this transition has been difficult. There is documentation of significant discord or difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider charted that the patient has support from his niece and nephew but is otherwise completely isolated. A few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4) since previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. The patient improved while at the RTC until November 2021, but since that time, the patient has been struggling outside of such a structured setting. For dimension 6, the patient has shown minimal engagement and recovery (score 4) due to the patients difficulty accepting any responsibility for recovery or accepting the reality of his symptoms and dysfunction. The patient has demonstrated trouble engaging with treatment. The patient avoids contact with and use of treatment services if left to his own devices. These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services. Additionally, the patient scored a 4 in functional status, which also supports medically monitored residence-based services. Additionally, in terms of length of stay, the patient meets criteria for level 5C moderate intensity long-term residential treatment due to his chronic compromise in his ability to adequately care for himself and chronic and severe deficits in interpersonal skills. 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 not primarily for the convenience of the patient or provider. For these reasons, the requested RTC services for a minimum of 30 days are medically necessary for treatment of this patient based on the provided documentation.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.