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

Findings:  The physician reviewer found that 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 PHP services. For dimension 1, the patient has been at moderate risk of harm (score 3) due to a history of self-injurious behavior and continued suicidal ideation with plan but no intent at this time. The records document significant current suicidal ideation without intent or conscious plan and without past history. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) since being unable to work or go to school due to symptoms. The patient has conflicted relationships with family. The patient has shown significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has significant co-morbidity (score 3) with a history of severe alcohol and opioid use disorder with near fatal overdose in the past. The patients recent substance use which has had clearly detrimental effects on the presenting disorder is currently arrested through the use of a highly structured treatment setting. For dimension 4A, the patients recovery environment has been moderately stressful (score 3) due to recent homelessness secondary to behavioral health symptoms and substance use. The patient has significant discord in family relationships and easy exposure to substances outside treatment. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider noted that the patients parents are supportive though with some conflict around the patients substance use. The records indicate that a few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has shown moderate or equivocal response to treatment and recovery management (score 3). The provider charted that the patient has been in higher levels of care and maintaining sobriety and psychiatric stability within those highly structured settings. The patient has been in inpatient, RTC, and PHP levels of care without complete remission of symptoms. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has exhibited limited engagement and recovery (score 3) considering the patients significant variability in engagement from one day to the next. The records document that the patient has some variability, hesitation or uncertainty in acceptance or understanding of illness and disability. These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services. Moreover, the PHP services were and are 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.