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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) 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.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. The patient has schizophrenia and had a history of suicidal ideation and current delusions that his family had been replaced by imposters. He did not want to live with them due to intense paranoid delusions that they wanted him dead. He continued to have this delusion and was fearful of returning there. At the residential treatment center, he was noted to have significant trouble with activities of daily living and had a decreased ability to care for himself in his current environment. Following his admission to the residential treatment center, he did not report any suicidal ideation or homicidal ideation. The patient therefore had no active suicidal or homicidal ideation, but he was in extreme distress, and a history of suicidal or homicidal behavior existed. [Score 3  moderate risk of harm]For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. Due to the patients mental illness, he was delusional about his family and believed that they had been replaced by imposters, and he was fearful that they were trying to kill him. The patient was too paranoid to return to his family home, and this placed a strain on his relationship with his family. The patient had significant deterioration in his ability to fulfill responsibilities and obligations. The serious impairment stemmed from a serious decrease in the quality of his interpersonal interactions and from his consistently conflictual disrupted relations with others. [Score 4  serious impairment]For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The submitted records do not include evidence of medical illness, substance use disorders, or psychiatric disturbances apart from the patients presenting disorder. [Score 1- no co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient had a highly stressful recovery environment due to serious disruption of family milieu due to severe conflict from his delusion. [Score 4 highly stressful environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. Although the patients parents were supportive, he was delusional about them and unwilling to use supports available in a constructive manner. [Score 4- minimal support in environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient had multiple medication trials and had trouble with both efficacy and tolerability. He has had three relapses with little sustained improvement. The patients previous treatment had not achieved complete remission or optimal control of symptoms even with repeated exposure. [Score 4- poor response to treatment and recovery management]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient did not have good insight into his psychiatric illness and his need for treatment. He appeared to be in the contemplative stage of change and had difficulty remembering to take his medications every day even with staff assistance. [Score 4- minimal engagement and recovery]These findings give the patient a composite score of 24, which corresponds with Level 5, Medically Monitored Residential Services. Level 5 is consistent with a residential treatment center (RTC) level of care. Accordingly, the residential treatment center (RTC) services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's 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.