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. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a history of chronic impulsive suicidal behavior or threats with current expressions or behavior representing a significant elevation from usual behavior. The patient endorsed ongoing intermittent suicidal ideation in the context of her depressive symptoms and eating disorder. The patient had a history of suicide attempts before admission to the RTC. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to consistently conflictual relationships with others, including impulsive behaviors. The patient reported severely disrupted sleep and was unemployed. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity due to the presence of primary diagnoses of anorexia and major depressive disorder along with uncontrolled alcohol use disorder. The patient reported being sober for six months before relapsing one week before admission to the RTC. Her psychiatric conditions were clearly disabling and interacted with, and seriously impaired, her ability to recover from alcohol use disorder. The patients medical conditions including tachycardia, dizziness, palpitations, and a history of hypotension, vision changes, and headaches upon standing that were made worse by her existing eating disorder. 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 severe discord and conflict in the family, and alienation from other social relationships, which were completely lacking.  With regard to level of support of the recovery environment, the records support a score of 3 as the patient had few supportive resources in her current environment that were capable of providing needed help. The patients parents were her only true source of support and her relationship with them was tumultuous. When available, the patient appeared to only partially utilize resources. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment, with symptoms of severe anorexia nervosa for a number of years, despite a number of interventions at various intensity levels. With regard to treatment acceptance and engagement, the records support a score of 4. The patient had extremely limited insight into her condition, minimizing her depressive symptoms and anxiety symptoms. The patient also consistently denied serious eating disorder symptoms but was noted to compulsively exercise in order to cope with her disturbed body image. These clinical findings are consistent with rarely, if ever, being able to accept the reality of illness or any disability that accompanies it, although the patient may acknowledge some difficulties in living with her condition. Thus, the patient had a total score of 25. In this case, the recommended level of care was medically monitored residence-based services. In this patients case, RTC 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, RTC 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 with sub-specialty certification in child and adolescent 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.