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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 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 a suicide attempt and continued suicidal ideation with a plan to overdose along with a recent increase in self-harm. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to an inability to work in a professional job that used her degree currently due to the severity of symptoms. The patient lives with her family but has been isolating, not interacting with her family and avoiding her girlfriend. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to a history of substance use, without any recent use, and numerous medical problems including hypothyroidism and fibromyalgia, which may worsen depressive symptoms and contribute to her presentation. The patients eating disorder is complicated by hypothyroidism, posttraumatic stress disorder (PTSD), and depressive symptoms. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment as she lives with family but is isolated from them. With regard to level of support of the recovery environment, the records support a score of 4 as the patient has limited support, isolating herself completely, even from her girlfriend. 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 she reported a previous RTC attempt and has  consistently been in outpatient treatment without any sustained benefit and without a complete remission of symptoms. With regard to treatment acceptance and engagement, the records support a score of 3. The patient is noted to have limited confidence to change despite intentions to do so and limited ability to accept responsibility for her recovery. Thus, the patient has a total score of 24. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm noted, the patient meets LOCUS 5b extended stay criteria.  In this patients case, RTC level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services 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 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 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.