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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services. 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, this patient met the criteria for the PHP services. For dimension 1, the patient was at moderate risk of harm (score 3) due to some evidence of self-neglect and decrease in ability to care for herself in her current environment, due to difficulty in adhering to meal plan when not being monitored. For dimension 2, the patient demonstrated moderate functional impairment (score 3) given her significant disturbances in physical functioning as evidenced by struggles with food intake, as well as her stabilization in weight achieved in a highly structured setting. For dimension 3, the patient has significant comorbidities (score 3) with gastrointestinal complaints that she associates with her eating solid foods. The patient has a medical condition that may adversely affect the course of the presenting disorder. For dimension 4, the patients recovery environment was moderately stressful (score 3) due to concerns related to sustained decline in health status. The patients recovery environment was supportive (score 2) as professional supports were available and effectively engaged. For dimension 5, the patient exhibited moderate response to treatment and recovery management (score 3). The records document that the patient was transitioned to PHP from RTC level of care. The records suggest that previous treatment exposures have been marked by minimal effort or motivation and no significant success or recovery period was achieved. For dimension 6, the patient has shown limited engagement (score 3) with little insight into the importance of her illness and limited ability to accept responsibility for recovery. The patient has some variability, hesitation, or uncertainty in acceptance or understanding of illness and disability. These findings give the patient a composite score of 20, which is consistent with medically monitored community based services, such as PHP. The patients combination of significant medical and psychiatric symptoms warranted close daily support and monitoring. For these reasons, the PHP level of care services provided were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 * 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.