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 any or all mental health residential treatment center (RTC) level of care. Findings:  The physician reviewer found that 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 3. The patient has a significant risk of harm, due to a history of a suicide attempt without current suicidal ideation. The records noted that the patient was recently binge using alcohol and some evidence of self-neglect.  In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient has conflicted relationships with those around her and has been isolating. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to the presence of significant alcohol use prior to treatment, posing a serious threat to her health if unchanged and posing a serious barrier to recovery from psychiatric symptoms. The patient reported that she would have difficulty maintaining sobriety outside of treatment.   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 being more isolated recently with significant discord in her relationships. She has easy exposure and access to alcohol at home. With regard to level of support of the recovery environment, the records support a score of 4 as the patient has very few or actual sources of support available with a conflictual marital relationship and limited other support.  In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, with continued use of alcohol throughout prior treatment attempts and with prior treatment not achieving remission of her symptoms. With regard to treatment acceptance and engagement, the records support a score of 3. The patient has some variability and hesitation in her ability to engage in treatment, with anxiety interfering with her ability to follow-through on treatment recommendations and difficulty making use of available resources independently. Thus, the patient has a total score of 24. The records support a 4 in terms of comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the comorbidity noted, the patient meets LOCUS 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, mental health RTC level of care was and is 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.