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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for psychiatric 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 a history of two past suicide attempts, attempts at self-harm, and concerns that she has relapsed with substance use. The patient demonstrates impulsivity, as she has run away from home, and is showing active depression and anxiety related symptoms. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to conflict from not being able to fulfill her ambitions as a successful professional dancer, and struggles with self-harm andsubstance use. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to the presence of substance abuse with substance-induced psychosis with hallucinations, major depressive disorder, generalized anxiety disorder, and unspecified eating disorder. The patient has medical diagnoses that impact her functioning, including hip dysplasia, and flexor hallucis longus tendinitis, which have compromised her ability to dance. 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 her fathers drinking and anger issues, her mothers depression, and her brothers mental health diagnoses. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has had challenges with familial relationships and appears to have relapsed in substance use recently due to limited support. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, with ongoing difficulties with medication compliance and adhering to therapeutic recommendations within the community, such as illicit substance abstinence. With regard to treatment acceptance an engagement, the records support a score of 3. The patient has had challenges with maintaining engagement, demonstrated by poor medication compliance, concerns regarding substance use, continued eating disorder symptoms, and ongoing struggles with depression and anxiety symptoms. Thus, the patient has a total score of 24. In this case, the recommended level of care is medically monitored residence-based services. Therefore, psychiatric residential treatment center (RTC) services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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 with sub-specialty certification in child and adolescent 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.