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

Nature of Statutory Criteria/Case Summary: An enrollee 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 (AStressors, and B-Supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others. The patient was seriously at risk, as he had voiced paranoia, thought broadcasting and intermittent suicidal ideation. The patients psychosis compromised his ability to be adequately aware of his environment, given his paranoia and subsequent misinterpretation of reality. Due to his psychosis, the patient had a compromised ability to care adequately for himself. [Score 4  serious risk of harm]For dimension 2  Function. This dimension assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. On examination, the patient was disheveled with a decline in his activities of daily living, and he was withdrawn. The patient had deficits in interpersonal relationships as well as legal problems. He was also unemployed. [Score 3  moderate impairment]For dimension 3  Comorbidity. This dimension assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient had sustained a traumatic brain injury from a fall and was impulsive as a result. The patient also suffered from tardive dyskinesia. [Score 3- significant co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient had tension with his family as a result of his psychosis and was under a restraining order. The patient was homeless as a result. He was also expecting twins later in the year and did not have a supportive home life. [Score 4 highly stressful environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient's mother was supportive, but there was significant strife as a result of the patients mental illness. [Score 3- limited support in environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient had failed in his previous treatment with an outpatient psychiatrist. He was currently on Clozaril, which is a medication for refractory symptoms. Records reflect that the patient had not previously achieved complete remission of symptoms. [Score 4- poor response to treatment and recovery management]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient was adherent with treatment, yet he required a great deal of encouragement and support to connect with treatment resources. [Score 3- limited engagement and recovery]These findings give the patient a composite score of 24, which corresponds with Level 5, Medically Monitored Residential Services. Level 5 is consistent with a Residential Treatment Center (RTC) level of care. Accordingly, the Residential Treatment Center (RTC) services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's 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.