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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any 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 had a significant risk of harm, due to periods of transient suicidal ideation, with impulsive anger and distress, without intent to act. The patient agreed to enter treatment at his parents request, and while these feelings and thoughts appeared to have dissipated to some degree by the time of admission, they re-emerged at various times during treatment. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to ongoing difficulties with interpersonal relations and periods of impulsive anger and self-directed aggression and pain. This behavior was not present at the time of admission, and the patient was doing well with treatment and showed no signs of these conditions. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity due to the occasional use of cannabis. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient had a mildly stressful environment due to the breakup of an internet relationship with a woman.With regard to level of support of the recovery environment, the records support a score of 2 as the patients parents were very supportive and willing to engage in treatment, and the patient appeared to have supportive friendships. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment, as the records did not document recent treatment nor his response. With regard to treatment acceptance and engagement, the records support a score of 2. The patient recognized his illness and was working on changing his behaviors. He appeared to accept responsibility for making these changes and engaged in treatment. Thus, the patient had a total score of 17. In this case, the recommended level of care is high intensity community-based services. Therefore, RTC services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.