Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 39-year-old female with chronic paranoid schizophrenia. The patient has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center care provided from 5/22/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  The physician reviewer found that 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 met the criteria for psychiatric residential treatment provided from 5/22/19 onward. For dimension 1, risk of harm, the records support a score of 4. This dimension assesses potential for harm to self or others. Although the patient does not have suicidal or homicidal ideation, she does demonstrate a consistent clear compromise in her ability to care adequately for herself or to be adequately aware of her environment due to her chronic, impairing symptoms of schizophrenia. For dimension 2, function, the records support a score of 5. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with, maintain physical functioning and capacity for self-care. The patient demonstrates a severe impairment in functional status. She withdraws completely, spending days in her room without eating or taking care of her activities of daily living. The patient has complete withdrawal from social interactions and complete neglect of her personal hygiene and an inability to tend to her basic needs, such as food intake. For dimension 3, comorbidity, the records support a score of 5. 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. Prior to moving to the residence, the patient had neglected her physical state, gaining weight due to inactivity. The patient had neglected any medical appointments during that time as well. While at the current facility, she has been attending to medical appointments during which medical issues were identified, including hypertension, and in August 2019, papilledema was identified. Without the assistance of the residential staff, patients health might have suffered, but they got her to the emergency room for further evaluation and treatment. For Recovery Environment dimension 4A, stress, the records support a score of 4. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. Prior to moving to the residence, the patient was unable to provide for her physical and material well-being outside of a structured, residential facility.For Recovery Environment dimension 4B, support, the records support a score of 4. This dimension assesses the presence of family and social support to augment the recovery environment. Although the patients mother is her greatest advocate, she has a limited ability to provide all the support that the patient needs. For dimension 5, treatment and recovery history, the records support a score of 4. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient has had limited improvement in her ability to function in prior placements. For dimension 6, engagement, the records support a score of 5. This dimension assesses a persons understanding of their illness and treatment, and ability and willingness to engage in the treatment process. Prior to admission to the current residential program, the patient was completely isolated, guarded, paranoid and unable to engage in recovery due to her symptoms and lack of engagement. These findings give the patient a composite score of 31, which is consistent with medically monitored residence-based services. Per LOCUS, the patients scores of 4 for risk of harm and 5 for functional status also support treatment at Level 6 medically monitored residence-based services level of care. For these reasons, the patients psychiatric residential treatment provided from 5/22/19 onward was and is medically necessary. Additionally, based on the patients presentation and the LOCUS criteria, the patient meets criteria for medically managed residence-based services, level 6, but more specifically, since this is not an acute decompensation but a chronic lack of ability to function independently would qualify the patient for level 6B or medically managed extended care residential programs, which is a longer duration of treatment until the patient is stable enough to step down in intensity of care.