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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided at Reasons Eating Disorder Center (BHC Alhambra Hospital). 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 RTC services.With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm due to continued suicidal ideation with a plan.  In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment as the patient reported self-harm behaviors and continued binging and purging.  With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to the presence of morbid obesity with diabetes mellitus type 2 and polycystic ovary syndrome, limiting the medications she can be prescribed so as not to worsen her glucose control and complicating the treatment of her eating disorder.  In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to self-isolation and perceived pressure to perform that surpasses her ability to meet obligations.  With regard to level of support of the recovery environment, the records support a score of 3 as the records noted limited or poor social support. 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 not achieved complete remission of symptoms with previous treatment.With regard to treatment acceptance and engagement, the records support a score of 4. The patient continues to binge and purge while in RTC. Thus, the patient has a total score of 24. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm noted, the patient meets Level 5b extended stay criteria. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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 services provided at Reasons Eating Disorder Center (BHC Alhambra Hospital) were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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.