Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 21-year-old female enrollee has requested reimbursement for adult mental health residential treatment center services provided from 3/12/19 through 12/20/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollee, who has been diagnosed with borderline personality disorder and substance use disorder, in remission. The physician reviewer found that the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) provides a framework for determining the appropriate level of care in patients with mental health treatment needs. With regard to risk of harm, the records support a score of 3. The patient had a moderate risk as she had periods of extreme distress and a history of suicidal ideation. She also had excessive usage of substances that resulted in harmful behaviors in the past. In terms of functional status, the records support a score of 3. The patient had moderate impairment as she had been recently conflicted, withdrawn and alienated in most of her relationships. She had significant deterioration in ability to fulfill responsibilities and obligations to school, self and family. She had severe deficits in interpersonal relationships, ability to engage in socially constructive activities and to maintain responsibilities. Recent gains were achieved while participating in treatment in a structured setting. With regard to medical and addictive comorbidity, the records support a score of 3. The patient had significant addictive comorbidity. There was recent substance abuse that had clearly detrimental effects, which has been temporarily arrested through the use of a highly structured setting. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to significant discord or difficulties in family milieu due to recent death of grandparents, and conflict between mother and patient. She had recently failed out of college. She perceived tremendous pressure to perform scholastically that surpassed her ability to meet obligations in an adequate manner. With regard to level of support of the recovery environment, the records support a score of 3. The patient had limited support. She was refusing to see her outpatient psychiatrist and therapist for the 2 months preceding the crisis. She did have support from her family. In terms of treatment and recovery history, the records support a score of 3. The patient had a moderate response to treatment and recovery management. Her current treatment had not achieved complete control of symptoms or optimal control of symptoms. Previous treatment exposures were marked by minimal motivation. The partial recovery has only been maintained with strong professional support in a structured setting. With regard to engagement and recovery status, the records support a score of 3. The patient had limited engagement and recovery. She has had variability and uncertainty in acceptance and understanding of illness. She at times lacked confidence to change despite intentions to do so. She had a fluctuating ability to accept responsibility for recovery. Thus, the patient has a composite score of 21, which indicates that medically monitored non-residential services would be the medically necessary level of care. Services included in this level of care would typically be described as partial hospital programs or as assertive community treatment programs. Intensive treatment should be provided at least 5 days per week and include individual, group, and family therapy depending on the patient's needs. Therefore, the records do not support the medical necessity of residential level of care during the dates of service at issue. Thus, adult mental health residential treatment center services provided from 3/12/19 through 12/20/19 were not medically necessary for the treatment of this patient.