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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) level of care. Findings:  The physician reviewer found that 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 1 The patient has a minimal risk of harm. The records did not document that the patient is impulsive or has perceptual disturbances. The patients Patient Health Questionnaire (PHQ)-9 score was two, indicating minimal to no depression. The patient is currently in assisted living, and the records did not appear to document concerns from the assisted living facility regarding any risks.  In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment due to an episode of depression and failure to thrive in 2021. The patients PHQ-9 score was two, indicating minimal to no depression. The patient has requested that medications be discontinued. A neurology assessment ruled out cognitive decline. The patient is being monitored at an assisted living facility and does not present with psychiatric issues. With regard to comorbidity, the records support a score of 2. The records did not document a disability based on psychiatric or neurologic assessments, although the records noted a concern of ruling out autism spectrum disorder. The patient was noted as having some medical issues that did not impair his ability to function in society. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient has a mildly stressful environment as the records noted that the patient was guarded. The patients niece, who has Power of Attorney, reported that her father, the patients brother, had recently passed away. With regard to level of support of the recovery environment, the records support a score of 2 as the patient is currently in an assisted living facility, with staff to monitor if the patient is declining or losing weight. While the patients niece is advocating for residential placement, it does not appear that the assisted living facility, or the patients psychiatrist or neurology team share her concerns. In terms of resiliency and treatment history, the records support a score of 2. The patient has significant resiliency and/or response to treatment, reporting that he does not desire a higher level of care and that he would like to stop medications. With regard to treatment acceptance and engagement, the records support a score of 2. The patient was guarded, raising concerns of ruling out a diagnosis of autism spectrum disorder. The patient has requested that his medication be discontinued, as opposed to discontinuing his medications on his own, indicating engagement in care. Thus, the patient has a total score of 13. In this case, the recommended level of care is recovery/maintenance services. In this patients case, residential treatment center level of care is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, residential treatment center level of care is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.