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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the last five days of treatment in a partial hospitalization program (PHP). 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 3. The patient had a significant risk of harm. Although much improved compared to the severe self-neglect on admission to RTC on 7/28/21, the patient continued to require prompting for his ADLs and required the structure of the program to regulate his self-care. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to continued struggles with social interactions and withdrawal. The patient had made recent gains only while participating in treatment and in a protected setting.  With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to the presence of numerous medical diagnoses, including high cholesterol and GERD, and a hospitalization for malnutrition and dehydration. Although improved while in this structured treatment setting, the patients malnutrition and medical problems could have worsened without such additional support.  In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment since his retirement as a teacher, with depression and self-care. The patient had declining health and reported easily feeling overwhelmed. With regard to level of support of the recovery environment, the records support a score of 4 as the patients had a limited support group. The patient was single and did not have a social network due to isolating. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, without a psychiatric history, and at least partial recovery this year only with strong professional support in structured settings. With regard to treatment acceptance and engagement, the records support a score of 3. The patient continued to have a difficult time engaging in treatment, sitting in silence with treatment providers, easily feeling overwhelmed. Thus, the patient has a total score of 22. In this case, the recommended level of care is medically monitored community-based services. In this patients case, PHP 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, the last five days of treatment in a PHP 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.