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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage 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 meets the criteria for PHP level of care. For dimension 1, the patient has been at moderate risk of harm (score 3) due to progressively worsening intrusive suicidal ideation though without clear plan or intent and without past history of suicide attempt. Significant current suicidal ideation without intent or conscious plan and without past history. For dimension 2, the patient demonstrates moderate functional impairment (score 3) since she has been unable to work and is having significantly conflicted relationships, leading to her recent housing transition. Recently conflicted, withdrawn, alienated or otherwise troubled in most significant relationships, but maintains control of any impulsive, aggressive or abusive behaviors. For dimension 3, the patient has significant comorbidities (score 3) with asthma and eczema, as well as significant psychiatric symptoms. The patient has been evaluated in the emergency department and by neurology for abnormal movements, which she attributes to medications, and supports close monitoring when starting a new medication. Medical conditions exist, or have potential to develop, which may require significant medical monitoring. For dimension 4A, the patients recovery environment is moderately stressful (score 3) considering her significant discord in relationships with others, causing issues in her job and housing. The patient is in the midst of a transition in her housing as well as a transition with her psychotherapist. Significant discord or difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment provides limited support (score 3) given her conflicted relationships. The patient has limited support, and she is not willing to engage with current supports. Resources may be only partially utilized even when available. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4). The patient has been treated in multiple levels of care since the beginning of this year, including inpatient, RTC, PHP and IOP. The patient has demonstrated a poor response to these previous treatments without optimal control of her symptoms even with intensive treatment. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient has shown limited engagement and recovery (score 3) given her motivation for treatment but has some variability and relates to treatment team with some difficulty. She has trouble accepting responsibility for her recovery. Has limited ability to accept responsibility for recovery. These findings give the patient a composite score of 22, which is consistent with medically monitored community-based services or PHP. For these reasons, the requested PHP services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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.