Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 41-year-old female. The patient has requested reimbursement and prospective 
authorization and coverage for inpatient residential treatment from 5/1/21 and forward. The 
Health Insurer has denied this request and reported that the services at issue were not and are 
not medically necessary for the treatment of this patient. 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 3. The patient has a significant risk of harm, due to consistent evidence of self-
neglect and need for direction from program staff to assist in patients self-care, without suicidal 
ideation or a history of past suicide attempts. In terms of functional status, the records support 
a score of 3. The documentation noted moderate functional impairment due to the patient 
consistently choosing to isolate herself, although improving in her ability to fulfill responsibilities 
and manage her basic needs while participating in treatment in a structured setting. With regard 
to comorbidity, the records support a score of 3. The patient has significant comorbidity. The 
patient is overweight, which can be worsened by her medications, and reports urinary issues, 
which may be worsened by her treatment. The records did not note substance use issues. In 
terms of level of stress of the recovery environment, the records support a score of 2. The patient 
has a mildly stressful environment. She has been at the RTC for quite some time now, since at 
least 2020. It appears that the patient was unable to maintain a job prior to her admission and 
continues  to  have  some  discomfort  about  her  responsibilities  at  the  program,  repeatedly 
checking with staff for direction. With regard to level of support of the recovery environment, 
the records support a score of 3 as the patients mother is actively involved, but the patient 
isolates herself and has limited ability to utilize resources independently. In terms of resiliency 
and treatment history, the records support a score of 3. The patient has moderate or equivocal 
response to treatment, as she has been hospitalized psychiatrically several times in the past and 
her partial recovery has been maintained only with strong professional support in structured 
settings. With regard to treatment acceptance and engagement, the records support a score of 
4. The patient is unable to accept the reality of her illness but acknowledges some difficulties 
associated with it, although reporting that these difficulties are the result of a UTI. Thus, the 
patient has a total score of 21. In this case, the recommended level of care is medically monitored 
nonresidential services. Therefore, inpatient residential treatment from 5/1/21 and forward was 
not and is not medically necessary for the treatment of this patient.