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. 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 criteria to this patients clinical documentation, the RTC services were medically necessary for treatment of this patient. The patient was at moderate risk of harm (score  3) due to a recent passive suicidal ideation without plan after initiation of a safety plan agreement. The provider requested the patient sign a safety contract due to apparent unsafe behaviors. The patient demonstrated serious functional impairment (score  4), given her inability to fulfill responsibilities due to her symptoms. The patient was not in school or working, and was unable to attend treatment due to a low functional level. The progress notes indicate that the patient had continued symptoms of dissociation and eating disorder behaviors. The patient had some documented medical, addictive and psychiatric comorbidity (score  3), due to continued substance use during treatment and poor nutritional status related to her eating disorder. The patients recovery environment was moderately stressful (score  3) due to family discord. The patients recovery environment was not supportive (score  4), given the lack of family support and inability to attend treatment. Her treatment and recovery history were limited (score  5), given her minimal past treatment response in several different levels of care, and interfering behaviors during her recent residential treatment. The patients engagement was not described as constructive (score  4), as she inaccurately reported her symptoms, refused to follow a meal plan on numerous occasions, and left treatment groups several times per session. She was ultimately discharged due to alcohol use at the RTC along with sharing the alcohol with peers. This gives the patients presentation a composite score of 26, which correlates with RTC level of care services. Therefore, the RTC services were medically necessary for 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.