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

Nature of Statutory Criteria/Case Summary: 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 to continued intermittent passive to active suicidal ideation even while in the RTC, requiring admission to the inpatient psychiatric unit intermittently and with a plan to run into traffic. The patient is compromised in his ability to care adequately for himself and awareness of his environment due to excessive substance use, an inability to abstain from substance use while home, and continued severe psychotic symptoms. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient is unable to attend school or work due to severe symptoms. The patient is quite psychotic, paranoid, and disorganized with serious decrease in his interpersonal interactions with consistently conflictual relations with others. The records noted that the patient was facing legal consequences from assaultive behavior toward healthcare workers during the course of his RTC treatment. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to the presence of uncontrolled substance use outside of RTC posing a serious barrier to his recovery from his psychotic and mood symptoms. Even in the course of RTC treatment, the patient ran away from treatment to seek out substances, sabotaging his progress.  In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment. Although the patient has supportive relationships with his parents, his poor reality testing and intense psychotic symptoms interfere with his ability to trust his parents and create discord in these important relationships. Due to his psychotic symptoms, the patient isolates himself from social interaction.  With regard to level of support of the recovery environment, the records support a score of 3 as the patient has limited support due to isolating himself from others and distancing himself from his parents due to his paranoid symptoms. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as he has been hospitalized psychiatrically repeatedly over the last couple years, even while in RTC. The patient has been denied admission to an intensive outpatient program (IOP), and has been unable to maintain any gains attained in intensive treatment even for limited periods of time.  With regard to treatment acceptance and engagement, the records support a score of 4. The patient is quite difficult to engage in treatment, with psychotic symptoms interfering with his ability to accept reality and to trust treatment providers. Thus, the patient has a total score of 26. The records support a 4 in terms of functional status, level of risk, and comorbidities. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment, elevated risk of harm noted, and comorbidities noted, the patient meets LOCUS 5c 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.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.