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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) 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 had a significant risk of harm, due to intermittently endorsing passive suicidal ideation without plan or intent and a history of self-injurious behavior. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to isolating herself and conflictual relationships with her mother.   With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to initially minimizing the presence of alcohol use, which she later reported as being daily. The records noted a history of seizure disorder, asthma, and abdominal pain, for which the patient received treatment in the emergency department, complicating treatment of her eating disorder. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient had a moderately stressful environment due to being isolated socially. She shared a home environment with several people and reported a chaotic living situation. With regard to level of support of the recovery environment, the records support a score of 3 as the patient lived with three roommates but had alienated herself from most social supports and had a conflictual relationship with her mother. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, with unclear response and ability to maintain significant recovery despite being in outpatient treatment.  With regard to treatment acceptance and engagement, the records support a score of 3. The patient had a difficult time engaging in treatment, with the records noting that she often left group sessions, was dysregulated, or presented late to sessions.  She had limited ability to accept responsibility for her recovery.  Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored community-based services. In this patients case, PHP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, PHP services were medically necessary for the 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.