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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential treatment center (RTC) services.In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining the necessary level of care for adults. Taking the above into account, the patient may be assigned a risk of harm rating of 5, which corresponds with extreme risk of harm. Since being discharged from the eating disorder intensive outpatient program (EDIOP), the patient has lost more weight, is eating less than 700 calories per day, and has been symptomatic with bradycardia on two documented occasions. This reflects clear compromise of the patients ability to care for herself with evidence of deterioration in physical condition. The patient may be assigned a functional status rating of 5 to reflect severe impairment. This scoring reflects that the patient has been noted to be eating less than 700 calories per day, engaging in purging behaviors, and has had recent documented symptomatic bradycardia with a pulse in the 35-40 range. The patient has been on medical leave from work, and notes from her most recent stay at a residential treatment center level of care indicate that she was unable to provide appropriate self-care without staff supervision and support. This reflects extreme disruption in physical functioning causing serious harm to health and well-being. In assessing the patients medical, addictive, and psychiatric co-morbidity, the patient may be assigned a comorbidity rating of 4, as the patient has major co-morbidity. This is because the patient has been diagnosed with major depressive disorder and endorses depressed mood, low energy, significant anxiety, and obsessionality. Notes also reflect that the patient recently endorsed passive suicidality on one occasion. The patients recovery environment may be assigned a level of stress rating of 3, to correspond with a moderately stressful environment. The patient has gone through a divorce within the past two years and has been unable to work due to her illness. The patients recovery environment may be assigned a level of support rating of 3, to correspond with limited support in her environment. The patient was discharged from an EDIOP for lack of progress toward treatment goals and was to start an outpatient treatment plan. The patient was clearly distressed with this change in her treatment and felt that she was lacking in supports. With regard to treatment and recovery history, the patient may be assigned a rating of 3 to reflect moderate or equivocal response to treatment and recovery management. The patient was first diagnosed with anorexia eight months ago and she has had an inpatient hospitalization, followed by partial hospitalization, and then EDIOP services. The patient had made some improvements with more intensive treatment but worsened after being discharged from an EDIOP. The patient may also be assigned an engagement and recovery status rating of 3, which corresponds with limited engagement. The patient has some uncertainty in her acceptance of her illness, and she lacks confidence to change despite her intentions to do so. When added together, these ratings produce a composite score of 26, which indicates that the patient qualifies for a Level 5: Medically Monitored Residential Services level of care. Accordingly, the requested residential treatment center (RTC) services are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's 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.