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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage 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. Applying the LOCUS framework, the patient meets the criteria for RTC services.For dimension 1, the patient has been at serious risk of harm (score 4) due to reports of suicidal ideation and self-injurious ideation continuously throughout the RTC admission. The patient endorses a plan to overdose if she is discharged and she has been unable to contract for her safety outside of RTC. Current suicidal ideation with expressed intentions and a past history of carrying out such behavior but without means for carrying out the behavior, or with some expressed inability or aversion to doing so, or with ability to contract for safety. For dimension 2, the patient has demonstrated serious functional impairment (score 4), given her great difficulty engaging in most interpersonal interactions with severe dissociative episodes and frequent flashbacks as well as significant withdrawal and avoidance of social interaction. Serious decrease in the quality of interpersonal interactions with consistently conflictual or otherwise disrupted relations with others, which may include impulsive, aggressive or abusive behaviors. For dimension 3, the patient has significant comorbidities (score 3), considering her thyroid issues that may be affecting her mood and anxiety symptoms. Additionally, the patient has a history of significant substance abuse and continued cravings and urges. Medical conditions exist which may be created or adversely affected by the existence of the presenting disorder. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The records document that the patient lives alone and is socially isolated. The patient reports that she has been experiencing great difficulty working due to her symptoms, with significant pressure to perform. This supports significant discord or difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment provides minimal support (score 4) due to the patient living alone without potential sources of support. Very few actual or potential sources of support are available. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4), given the patients continued struggles to maintain any recovery outside of a structured setting. The patient has been in various levels of care repeatedly, including RTC with self-harm and suicidal ideation within a couple days of discharge. Attempts to maintain whatever gains that can be attained in intensive treatment have limited success, even for limited time periods or in structured settings. For dimension 6, the patient has exhibited limited engagement and recovery (score 3), given her trouble relating to her treatment team and accessing care in the midst of a flashback. Given her history of significant trauma, the patients ability to trust her team was limited. The patient related to treatment with some difficulty and established few, if any, trusting relationships. These findings give the patient a composite score of 25, which is consistent with medically monitored residence-based services. Per LOCUS, the patients scores of 4 for risk of harm and functional status also support Level 5 medically monitored residence-based services. Additionally, the patient meets criteria for intermediate stay medically monitored residence-based services with treatment up to 60 days, given the presence of suicidal ideation, great difficulty in interpersonal relationships, and inability to function in work and co-occurring and complicating substance use disorders. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not for the convenience of the patient or provider. All told, the psychiatric RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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.