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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with major depressive disorder, adjustment disorder with mixed features, and bulimia nervosa in remission. The patient was admitted to a residential treatment center (RTC), with symptoms including excessive crying and ruminating about the failure of a recent relationship that led to her inability to work. The patients bulimia nervosa has reportedly been in remission. On admission, she denied substance use and current medical problems. Her laboratory results were within normal limits. She denied suicidal and homicidal ideation. There was no evidence of hallucinations or delusions. The patient was discharged to outpatient treatment with therapy, 12-step meetings, and follow-up with her primary care provider for continuing Celexa. At issue in this case is whether RTC level of care services that were provided were medically necessary for treatment of the patients medical condition. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm, the patients score is 1, due to no report of suicidal ideation on admission or during residential treatment. For functional status, the patients score is 2, due to the patient being unable to work as a result of her emotional state. She was able to perform activities of daily living, participate in therapy, and interact with others without difficulty. For comorbidity, the patients score is 1, due to no evidence of acute or chronic medical conditions requiring intensive intervention and no evidence of substance use disorder. For recovery environment level of stress, the patients score is 3, due to the patients recent relationship difficulty with an ex-boyfriend who is her neighbor. For recovery environment level of support, the score is 1, due to the patients friends and family supporting her treatment. For resiliency and treatment history, the patients score is 2, due to the patients bulimia nervosa being in remission for 16 years, and despite her relationship stress, she did not engage in bulimic behaviors and sought treatment. For acceptance and engagement, the patients score is 4, due to the patient endorsing not being depressed, despite crying excessively and being unable to work due to rumination. The patients composite LOCUS score is 14, which indicates low-intensity community-based level of care. Given these findings, the patient was a candidate for treatment in a less restrictive level of care than RTC. Therefore, RTC level of care services that were provided were not mecially necessary for the patient. Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.