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

Findings:  The physician reviewer found that An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center Services.At issue in this case is whether the Residential Treatment Center (RTC) services at issue and requested services were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A) to treat the enrollees mental health or substance use disorder. Medically necessary treatment of a mental health or substance use disorder is defined in Health and Safety Code section 1374.72(a)(3)(A) as follows:(A) For purposes of this section, medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i) In accordance with the generally accepted standards of mental health and substance use disorder care.(ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii) 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. 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, which corresponds with a low risk of harm. This dimension assesses a patients potential for harm to self or others, or having harm inflicted upon them. In this case, the patient had suicidal ideation in the past but denies current suicidal ideation.In terms of functional status, the records support a score of 3, which corresponds with moderate impairment. This dimension assesses the degree to which a patient can fulfill social responsibilities, interacts with others, maintains their physical functioning, as well as a patients capacity for self-care. In this instance, the patient is unable to work due to symptoms and has isolated from others.With regard to medical, addictive, and psychiatric comorbidities, the records support a score of 2, which corresponds with minor co-morbidity. 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 in addition to the presenting disorder. In this case, the patient struggles with binge eating disorder with metabolic side effects. Additionally, the patient has a history of alcohol and cannabis use disorders, though recent episodes of misuse have been self-limited.In terms of the level of stress of the recovery environment, the records support a score of 4, which corresponds with a highly stressful environment. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. In this case, the patient has had very conflictual relationships recently with family and is processing trauma at the hands of the patient's father.With regard to the level of support of the recovery environment, the records support a score of 3, which corresponds with limited support in the recovery environment. This dimension assesses the presence of family and social support to augment the recovery environment. In this case, the patient has self-isolated from most social supports outside husband, and due to the trauma symptoms, has isolated from the rest of the family, particularly the patient's father.In terms of treatment and recovery history, the records support a score of 4, which corresponds with poor response to treatment and recovery management. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. In this case, the patient has been in intensive treatment for the last 6 months without significant improvement of symptoms. The patient also attempted to get treatment at an IOP level of care but was referred for RTC services due to the severity of symptoms.With regard to engagement and recovery status, the records support a score of 3, which corresponds with limited engagement and recovery. This dimension assesses a patients understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. In this case, the patient is quite tense and withdrawn in treatment and has limited ability to accept responsibility for recovery.These findings give the patient a composite score of 21, which is consistent with Level 4 Medically Monitored Non-Residential Services. LOCUS documentation states that this level of care refers to services provided to patients capable of living in the community either in supportive or independent settings, but whose treatment needs require intensive management by a multi-disciplinary treatment team. Services, which would be included in this level of care have traditionally been described as partial hospitalization programs (PHP) and as assertive community treatment programs.The patients scores under the six-pronged LOCUS Dimensional Rating System consider the specific needs of the patient for the purpose of treating their illness and its symptoms. The LOCUS framework for determining the appropriate level of care for patients needing mental health treatment is consistent with generally accepted standards of mental health, and it provides determinations that are clinically appropriate in terms of type, frequency, extent, site, and duration. The LOCUS dimensions are also free from consideration of 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. Accordingly, the Residential Treatment Center (RTC) services at issue and requested services were not, and are not, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue and requested services were not, and are not, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A). Therefore, the Health Plans denial should be upheld.