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) level of care 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 had a serious risk of harm, due to continued suicidal ideation with a plan to overdose and a recent history of a near-lethal overdose. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient reported using drugs and alcohol while working. The patient reported being isolative, not leaving her apartment for weeks except to obtain alcohol and drugs. Even while at RTC, the patient was withdrawn and avoided almost all social interactions. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to the presence of alcohol and opioid use disorders with uncontrolled substance use outside of a structured setting and frequent relapses upon leaving treatment. The patients substance use worsened their mood symptoms and suicidality. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a highly stressful environment as she was on the verge of homelessness, having lost her apartment, and faced with potentially living on the street with ready and constant access to substances. With regard to level of support of the recovery environment, the records support a score of 3 as the patient had limited support, isolating herself and being dependent on her parents for support. 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 her prior treatment included RTC treatment without sustained benefit outside of a structured setting. With regard to treatment acceptance and engagement, the records support a score of 3. The patient had 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 26. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment, elevated risk of harm, and comorbidity noted, the patient met LOCUS 5b extended stay criteria.  In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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 level of care services were medically necessary for the 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.