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. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to a history of at least one suicide attempt by overdose, self-injury, and current passive suicidal ideation without intent or plan.  In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to being essentially housebound prior to RTC admission, avoiding all social interactions. While at the RTC, the records note that the patient continues to avoid social interactions, sitting away from the group and with consistently conflictual relations with others in the program. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of heavy alcohol and cannabis use prior to admission to RTC. The records noted that the patient was found drinking hand sanitizer in lieu of alcohol while at the RTC.  In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to being isolated, and unable to work or go to school due to symptoms. Her perception of the pressure to perform surpasses her ability to meet obligations and she has difficulty avoiding exposure to substances outside of treatment. With regard to level of support of the recovery environment, the records support a score of 3 as the patient has a conflictual relationship with her parents, pushing them away despite depending heavily on them, and has withdrawn from all other social contacts due to significant symptoms and substance use.   In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management as despite previous treatment in RTC and inpatient levels of care, the patient has not achieved complete remission of symptoms, continues to have significant symptoms, and is unable to pursue school or maintain a job because of these symptoms. With regard to treatment acceptance and engagement, the records support a score of 4. The patient has significant dysregulation and avoids contact with and use of treatment resources if left to her own devices. She has not attended several group sessions, and when she attends, the records note that she sits away from the group, disengaging throughout the group session.Thus, the patient has a total score of 24. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment noted, the patient meets 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 rendered were and are medically necessary for the 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.