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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage 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. Applying the LOCUS framework, this patient meets the criteria for PHP services. For dimension 1, the patient has been at serious risk of harm (score 4). The records document that the patient sustained a serious overdose on alcohol and Unisom resulting in psychosis and hospitalization. The patients presentation is consistent with a recent pattern of excessive substance use resulting in loss of self-control and clearly harmful behaviors with no demonstrated ability to abstain from use. For dimension 2, the patient has demonstrated moderate functional impairment (score 3) due to severe insomnia, which has been documented throughout the course of her stay in PHP. This is consistent with significant disturbances in physical functioning such as sleep, eating habits, activity level, or sexual appetite, but without a serious threat to health. For dimension 3, the patient has major comorbidity (score 4) considering that in addition to her primary diagnosis of major depressive disorder, severe, recurrent and post-traumatic stress disorder (PTSD), the patient also has significant alcohol use disorder that has led directly to two inpatient hospitalizations in the past six months. The patients presentation is consistent with uncontrolled substance use that occurs at a level that poses a serious threat to health if unchanged, and/or which poses a serious barrier to recovery from any co-occurring psychiatric disorder. Furthermore, the patient had elevated testosterone levels requiring work-up and referral to endocrinology during stay at PHP. For dimension 4A, the patients recovery environment has been mildly stressful (score 2). The provider noted that the patient has the presence of some ongoing or intermittent interpersonal conflict, alienation or other difficulties. The records document that the patients stepmother is on life-support and her son is incarcerated.   For dimension 4B, the patients recovery environment has been supportive (score 2). The provider noted that the patient has supportive resources that are not abundant but are capable of and willing to provide significant aid in times of need. Some elements of the patients support system are willing and able to participate in treatment if requested to do so and have capacity to effect needed changes. The patients husband drives the patient to daily treatment sessions. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4). The patient has required multiple recent inpatient hospitalizations in the previous six months, along with failure of intensive outpatient program (IOP) and PHP. The patients previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient has shown positive engagement and recovery (score 2) considering the patients significant understanding and acceptance of their illness and its effect on her ability to function. The patient has not been able to actively maintain changes made in the past. The patients composite LOCUS score is 21, which is consistent with medically monitored non-residential services. In addition, the requested PHP services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the requested PHP services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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.