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

Findings:  The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage 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 4. The patient has a serious risk of harm, due presenting with a history of suicidal ideation, a suicide attempt by walking into oncoming traffic, substance use, and delusions. The patient endorsed ongoing persecutory delusions and IOR and reported that the patient was at risk of harm from controlling entities. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the records noted that the patient was unable to work, had lost custody of children, and was fully consumed by substance use and psychotic symptoms. With regard to comorbidity, the records support a score of 4. The patient has Crohns disease, with treatment complicated due to the gastrointestinal effects of many medications, along with cannabis use which may have heightened psychotic symptoms and poses a serious threat to recovery.  In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to a recent trauma, the loss of custody of the patient's two children, isolation, and psychotic symptoms. With regard to level of support of the recovery environment, the records support a score of 4 as the patient only has mother for support. The patient is divorced, has lost custody of children, and reported self-isolation.In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management and has been hospitalized multiple times over the last two years without improvement in symptoms. With regard to treatment acceptance and engagement, the records support a score of 4. The patient questioned the need for treatment and for medications. The records noted that the patient has trouble understanding the role of substance use in the patient's recent decompensation and limited insight into symptoms. Thus, the patient has a total score of 26. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets Level 5b extended stay criteria. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue 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, RTC services were and are medically necessary for the treatment of this patient.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.