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 framework, this patient met the criteria for RTC services. For dimension 1, the patient was at moderate risk of harm (score 3) due to fluctuating passive suicidal ideation. The provider noted that the patient also has a history of binge drinking and impulsive behaviors. Binge or excessive use of substances resulted in potentially harmful behaviors in the past, but there have been no recent episodes. For dimension 2, the patient demonstrated moderate functional impairment (score 3) since she has been unable to work due to her symptoms. The patient has encountered multiple legal difficulties and she has conflict within her marriage related to her alcohol use. Significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has significant comorbidities (score 3) given her elevated blood pressure, edema, and dyspepsia. The patient required medication changes. Medical conditions exist, or have potential to develop, which required significant medical monitoring. For dimension 4A, the patients recovery environment is highly stressful (score 4). The records document that the patients husband is a heavy drinker and they have marital strife. She has recent legal problems due to her legal issues. Serious disruption of family or social milieu due to severe marital conflict. For dimension 4B, the patients recovery environment provided limited support (score 3) since the patient did not have an outpatient psychiatrist or therapist, and she was experiencing marital discord. Usual sources of support were somewhat ambivalent, alienated, difficult to access, or had a limited amount of resources they were willing or able to offer when needed. For dimension 5, the patient exhibited poor response to treatment and recovery management (score 4). The records document that she has gone through multiple relapses and did not maintain gains from her previous treatment. She remained at high risk of decompensation in a lower level of care. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient showed limited engagement and recovery (score 3) due to her disorganization. The provider noted that the patient struggled to adhere to treatment and follow instructions. The patient related to treatment with some difficulty and established few, if any, trusting relationships. This gives the patient a composite score of 23, which is consistent with medically monitored residence-based 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 with subspecialty certification in geriatric 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.