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 residential treatment center (RTC)  services. 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 4. The patient has a serious risk of harm. He is unable to provide a reliable history. The patient denies a history of suicide attempts, but described attempting to hang himself three months prior to admission. The records noted that the patient had burn marks from self-injurious behavior and was observed hitting himself. He had a recent pattern of substance use resulting in clearly harmful behaviors without any ability to abstain on his own. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient is unable to work due to severe symptoms. He is isolative with significant withdrawal from almost all social interactions, reporting that he stayed in bed in his room all day prior to admission to the RTC. The patient is internally preoccupied and difficult to engage in treatment.With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of methamphetamine and cannabis use, with clearly detrimental effects on his psychotic symptoms, which has been temporarily arrested in the highly structured RTC setting. 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 isolated to home. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has isolated himself from most social supports due to his symptoms and substance use. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, as he has been hospitalized multiple times in the last year, and is unable to maintain gains made outside of a structured treatment setting. With regard to treatment acceptance and engagement, the records support a score of 4. The patient has difficulty accepting the reality of his illness and need for ongoing treatment, and does not accept responsibility for his recovery. Thus, the patient has a total score of 25. The records support a 4 in terms of risk of harm and of functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets LOCUS 5b extended stay criteria.  This is consistent with the level of care that the patient received and is receiving at the RTC. 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, RTC services were and are 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.