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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for 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. 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 had a low risk of harm, without current suicidal or homicidal ideation, plan, intentions, or severe distress, but with possible transient or passive thoughts recently or in the past. In terms of functional status, the records support a score of 3. The documentation noted moderate impairment as the patients appearance and hygiene fell below usual standards on a frequent basis. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to primary diagnoses of obsessive compulsive disorder (OCD) and eating disorder, along with significant symptoms of generalized anxiety disorder, attention deficit hyperactivity disorder (ADHD), and mild depressive symptoms. This combination of diagnoses impacted the patients primary psychiatric disorders to a significant extent.In terms of level of stress of the recovery environment, the records support a score of 2.  The patient had a mildly stressful environment due to some ongoing or intermittent interpersonal conflict, alienation, or other difficulties, without other major environmental stressors. With regard to level of support of the recovery environment, the records support a score of 2 as the patient had supportive resources that, while not abundant, were capable of and willing to provide significant aid in times of need. She engaged with available professional supports. In terms of resiliency and treatment history, the records support a score of 2. The patient had significant resilience and/or response to treatment as her previous or current experience in treatment was successful in controlling most symptoms, although intensive or repeated exposures may have been required. The patient had not received inpatient, intensive outpatient program (IOP), or partial hospitalization program (PHP) prior to entering residential treatment. With regard to treatment acceptance and engagement, the records support a score of 2. The patient had significant understanding and acceptance of her illness and its effect on her function. She was willing to change and was actively working toward it, had a positive attitude toward recovery and treatment, was capable of developing trusting relationships, and used available resources independently when necessary. Thus, the patient has a total score of 16. In this case, the recommended level of care was low intensity community-based services. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, RTC services were not medically necessary for the 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.