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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) 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 the PHP services.For dimension 1, the patient was at moderate risk of harm (score 3) due to episodes of self-harm while in PHP. The patient denied suicidal ideation and she did not have a reported history of suicide attempts. The patient exhibited signs of consistent deficits in ability to care herself as evidenced by her difficulty following her meal plan, gaining weight, and compensatory exercise. The records document some evidence of self-neglect and decrease in ability to care for oneself in current environment. For dimension 2, the patient demonstrated moderate functional impairment (score 3) since the patient isolated herself from friends prior to admission. The patients self-care levels of eating have only occurred while in treatment. This supports recent gains in function were achieved while participating in treatment in a structured and protected setting. For dimension 3, the patient has major comorbidities (score 4) given her psychiatric diagnoses and co-occurring eating disorder with its multiple medical complications including prolonged/borderline QTc, chronic constipation, and secondary amenorrhea. The patient also has insomnia. Depression and anxiety can cause insomnia and insomnia can exacerbate psychiatric symptoms. Eating disorders can cause multiple medical complications. Based on the records, medical conditions exist which were clearly made worse by the existence of the presenting disorder, and medical conditions exist which clearly worsened the course and outcome of the presenting disorder. For dimension 4A, the patients recovery environment was moderately stressful (score 3) due to medical problems related to her eating disorder, which required hospitalization and moving across the country to participate in an in-person PHP. The records support concern related to sustained decline in health status. For dimension 4B, the patients recovery environment was supportive (score 2) based on her familys engagement in family therapy without the patient present during her treatment stay. Some elements of the support system were willing and able to participate in treatment if requested to do so and had capacity to effect needed changes. For dimension 5, the patient exhibited poor response to treatment and recovery management (score 4). Prior treatment has included ongoing outpatient treatment, antidepressant medication, medical hospitalization, and a virtual partial hospital program. Previous treatment failed to achieve complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 6, the patient has shown limited engagement and recovery (score 3) as noted in the medical records. According to the provider, the patient struggled to engage in individual and group therapy, and the patient refused to engage in family therapy. The patient showed some variability, hesitation or uncertainty in acceptance or understanding of illness and disability. These findings give the patient a composite score of 22, which is consistent with Level 4 medically monitored non-residential services. Moreover, the PHP services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the PHP 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 with subspecialty certification in child and adolescent 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.