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 partial hospitalization program (PHP) services for one month (28 visits). 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. Applying the LOCUS framework, the patient met the criteria for PHP services for one month (28 visits). For dimension 1, the patient has been at serious risk of harm (score 4) due to frequent self-injurious behavior.  For dimension 2, the patient has demonstrated moderate functional impairment (score 3) since the patient has been unable to attend school or work due to anxiety and depression. The patient is socially isolated and has a conflicted relationship with her parents. There is evidence of ongoing and variably severe deficits in interpersonal relationships, ability to engage in socially constructive activities, and ability to maintain responsibilities. For dimension 3, the patient has significant comorbidities (score 3). The records document that the patient has a skin disorder for which she is resistant to treat, and her skin is noted to bleed while in group sessions. The patient also has a history of regular cannabis use, in remission now, as well as asthma for which she uses inhalers. The records report medical conditions which may have been created or adversely affected by the existence of the presenting disorder, and which may adversely affect the course of the presenting disorder. For dimension 4A, the patients recovery environment is moderately stressful (score 3) given the patients social isolation with only relationships with her parents, though this relationship is conflicted. This supports significant discord or difficulties in family or other important relationships and alienation from social interaction. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider noted that the patients main social support are her parents with whom she has a conflicted relationship. She has a friend in Hawaii with whom she only has contact by text and she is otherwise socially isolated. The usual sources of support may be somewhat ambivalent, alienated, difficult to access, or have limited resources they are willing or able to offer when needed. For dimension 5, the patient has shown moderate or equivocal response to treatment and recovery management (score 3). Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. The patient was previously hospitalized twice and completed RTC. For dimension 6, the patient has shown limited engagement and recovery (score 3) due to variability and hesitation in her engagement in treatment. The provider noted that the patient has exhibited some difficulty accepting responsibility for her recovery. The records document that the patient has some variability, hesitation or uncertainty in acceptance or understanding of illness and disability, as well as accepting limited responsibility for recovery. Per LOCUS, these findings give the patient a composite score of 22, which is consistent with medically monitored community-based services. Moreover, the PHP services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the PHP services for one month (28 visits) were and are medically necessary for 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.