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 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. Applying the LOCUS framework, the patient met the criteria for RTC services.With regard to dimension 1, risk of harm, the records support a score of 4. This dimension assesses potential for harm to self or others. The patient had a suicide attempt prior to starting RTC and has continued to have suicidal ideation with vague plans throughout treatment.With regard to dimension 2, functional status, the records support a score of 4. This dimension assesses the degree to which the patient is able to fulfill social responsibilities, maintain physical functioning and capacity for self-care. The patient repeatedly failed to maintain personal hygiene and self-care. The records noted that she had been significantly isolative and was unable to perform close to usual standards in work, leading to the recent loss of her job. With regard to dimension 3, comorbidity, the records support a score of 3. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient minimized her substance use on admission to RTC, although she had cravings and mood symptoms associated to coming off the substances during her stay at the RTC. With regard to dimension 4A, level of support in the recovery environment, the records support a score of 3. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patient has had recent conflicts in her relationship with her husband and has lost her job. With regard to dimension 4B, level of support of the recovery environment, the records support a score of 3. This dimension assesses the presence of family and social support to augment the recovery environment. The patient has isolated herself from most social supports outside her husband, but she was noted to have significant conflicts with her husband. With regard to dimension 5, treatment and recovery history, the records support a score of 3. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient has attempted PHP but was noted to need a higher level of care.  With regard to dimension 6, engagement, the records support a score of 3. This dimension assesses an individuals understanding of his or her illness and treatment, and ability and willingness to engage in the treatment process. The records indicate that the patient was quite distracted in treatment and has limited ability to accept responsibility for recovery. These findings give the patient a composite score of 23, which is consistent with medically monitored residential services. Per LOCUS, the patients scores of 4 for risk of harm and functional status also support treatment at the RTC level of care. Therefore, psychiatric RTC services were and are medically necessary for the treatment of this patient. The services at issue were and are 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.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 th