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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Findings:  The physician reviewer found that 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. With regard to risk of harm, the records support a score of 3. The patient had significant risk of harm, due to endorsing suicidal ideation without intent or plan and a history of self-injurious behavior.  In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient had completely withdrawn from almost all social interactions due to the severity of his obsessive compulsive disorder (OCD) symptoms and time taken up by his rituals. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to the presence of psoriasis and significant adverse effects to medications indicated for OCD treatment, necessitating a trial of a mood stabilizer followed by the standard OCD treatments. The records noted that the patient was sensitive to even small medication changes. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment as he had been unable to function since finishing college, incapacitated by his OCD symptoms, and with perceptions and pressure to perform that surpasses his ability to meet obligations in an adequate manner.  With regard to level of support of the recovery environment, the records support a score of 3 as the patient had limited support, isolating himself to contact only with his parents. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management, as he had previously been hospitalized and participated in a specialized OCD outpatient program without benefit. With regard to treatment acceptance and engagement, the records support a score of 3. The patient had some variability and hesitation in accepting and trusting treatment providers and did not use available resources independently, requiring staff redirection and support. Thus, the patient had a total score of 23. In this case, the recommended level of care was medically monitored residence-based services. The records supported a 4 in terms of functional status. With the functional impairment noted, the patient met LOCUS 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 were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.