Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 24-year-old male with schizophrenia, anxiety disorder, and severe cannabis use 
disorder. The patient has requested reimbursement and prospective authorization and coverage 
for  adult  mental  health  residential  treatment  center  services  from  5/07/22  forward.  The 
physician reviewer found that 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 residential treatment center services 
provided 5/07/22 forward. For dimension 1, risk of harm, the records support a score of 4. This 
dimension assesses the potential for harm to self or others. The patient was admitted for 
residential treatment with command auditory hallucinations telling him to kill himself along with 
sense of worthlessness and hopelessness. As patient has slowly improved during residential 
treatment stay, he has denied any suicidal ideation in the period in question, although he has 
continued to be paranoid and with questionable continued psychotic symptoms, which would 
continue to put him at harm if they continue to be command in nature. For dimension 2, function, 
the records support a score of 4. This dimension assesses the degree to which a patient is able to 
fulfill social responsibilities and maintain physical functioning and capacity for self-care. This 
patient has great difficulty functioning normally, is significantly withdrawn, and avoids social 
interactions. He is unable to work or go to school and has difficulties with his grooming and taking 
care of his needs. For dimension 3, comorbidity, the records support a score of 3. This dimension 
assesses potential complications in the course of treatment due to acuity or disability related to 
co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient has 
continued  to  use  cannabis  prior  to  admission  to  the  residential  treatment  center  despite 
heightened depression, anxiety, and psychotic symptoms and is not motivated to stop using 
cannabis although use has been temporarily arrested through the structured treatment setting. 
For dimension 4A, level of stress of the recovery environment, the records support a score of 3. 
This  dimension  assesses  the  stressors  in  the  environment,  social  circumstances,  and 
interpersonal relationships. The patient has been isolated from others, unable to work due to his 
symptoms, and is financially dependent on his mother. Additionally, the patient has difficulty 
avoiding exposure to substances outside of treatment. For dimension 4B, level of support of the 
recovery environment, the records support a score of 3.  This dimension assesses the presence 
of family and social support to augment the recovery environment. The patient depends heavily 
on his mother, although he has withdrawn due to significant anxiety and psychotic symptoms. 
For dimension 5, treatment and recovery history, the records support a score of 4. This dimension 
assesses how past experiences with treatment and recovery might indicate how the patient 
might respond in the future. The patients previous treatment has not achieved complete 
remission of symptoms as he continues to have significant anxiety and psychotic symptoms and 
inability to pursue school or maintain a job because of these symptoms. He has engaged in 
intensive outpatient program (IOP) and several episodes of inpatient level of care without  sustained remission of symptoms. For dimension 6, engagement, the records support a score of 
4. This dimension assesses a patients understanding of his illness and treatment, and ability and 
willingness to engage in the treatment process. The patient has significant anxiety and psychotic 
symptoms and avoids contact with and use of treatment resources if left to his own devices. 
These findings give the patient a composite score of 25, which is consistent with medically 
monitored residence-based services or residential treatment. Additionally, scores of 4 in risk of 
harm and level of functioning necessitate treatment at his higher level of care. For these reasons, 
the adult mental health residential treatment center services provided from 5/7/22 forward were 
and are medically necessary for treatment of this patient.