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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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. Applying the LOCUS framework, this patient met the criteria for RTC services. For dimension 1, the patient was at serious risk of harm (score 4) due to her history of imminent suicide attempts via wanting to jump off a building, with at least two episodes when the patients spouse talked her down from a building ledge. The patient has a history of paranoia and high anxiety states with symptoms of severe hopelessness and helplessness. She presented as guarded in the hospital, focused on discharge, ruminative and anxious. She appeared to be an unreliable historian. There was current suicidal ideation with expressed intensions and past history of carrying out such behavior but without means for carrying out the behavior, or with some expressed inability or aversion to doing so. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her isolation and paranoid ideation. The patient reportedly engaged in bizarre behaviors over the prior year including shoplifting, refusing to speak to her in-laws, and going for days without sleep. The patient continued to be fearful of her husband leaving her while in the hospital and at the RTC. Serious disturbances in physical functioning such as weight change, disrupted sleep, or fatigue that threatened physical well-being. For dimension 3, the patient has significant comorbidities (score 3) considering her feelings of helplessness and suicidal ideation consistent with depressive symptoms. The patient also experienced severe anxiety with significant ruminations and panic attacks. The patient also underwent surgery in the past year with breast augmentation and abdominal reconstruction surgery seem to have contributed towards depression and anxiety with suicidal ideation. Medical conditions existed which may adversely affect the course of the presenting disorder. For dimension 4A, the patients recovery environment was highly stressful (score 4). The records document that the patient has three children and she was isolated from friends. The patient reported only having contact with her mother and husband prior to admission. The patient was unable to meet needs for physical and material well-being. For dimension 4B, the patients recovery environment provided limited support (score 3) given her isolation from friends with limited contact with her mother prior to admission. A few supportive resources existed in current environment and may be capable of providing some help if needed. For dimension 5, the patient exhibited poor response to treatment and recovery management (score 4) since previous or current treatment had not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. The patient was treated in outpatient therapy with medication management and IOP limited success. For dimension 6, the patient showed limited engagement and recovery (score 3) as the provider reported poor medication compliance and paranoid behaviors toward staff and her spouse. The patient presented as guarded and did not want to disclose details of suicidal thoughts. The patient has limited desire or lacks confidence to change despite intensions to do so. These findings give the patient a composite score of 25, which is consistent with medically monitored residence-based services. The records document that the patients mental health challenges necessitated stepdown from hospital level of care to RTC with 24-hour supervision and access to psychiatric services during this time given her fragile mental health status and ongoing risk of self-harm. Accordingly, the RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.