Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 20-year-old male who was admitted to a residential treatment center (RTC) on 8/18/22 
and presented for a psychiatric evaluation on 8/19/22. The records noted that the patient had 
previously been treated at the facilitys partial hospitalization program (PHP) but that the patient had 
been unable to maintain sobriety while in the program and after discharge. The physician reviewer 
found that the issue is whether residential behavioral health from 9/7/22 through discharge was and is 
medically necessary for the treatment of this patient. 
 
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 has a moderate risk of harm, 
due to extreme distress and a history of suicidal behaviors including a previous overdose, and self-harm 
by hitting himself, without active suicidal or homicidal ideation.  
In terms of functional status, the records support a score of 4. The documentation noted serious 
functional impairment due to serious disturbances in physical functioning, including disrupted sleep with 
nearly nightly nightmares and fatigue, that threaten his physical wellbeing.  
 
With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to 
the presence of multiple serious psychiatric symptoms, including insomnia, severe anxiety, obsessive 
thoughts, and depressive symptoms, which are clearly disabling and which interact with and seriously 
impair the patients ability to recover from his co-occurring alcohol and cannabis use disorders. 
 
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 ongoing significant discord and difficulties in his family, 
specifically major conflict in the relationship with his mother.  
 
With regard to level of support of the recovery environment, the records support a score of 3 as the 
patient has a few supportive resources in the current environment that may be capable of providing 
some help if needed including his brother and father.  
 
In terms of resiliency and treatment history, the records support a score of 4. The patient has poor 
response to treatment and recovery management, as prior and current treatment have not achieved 
complete remission of symptoms or optimal control of symptoms even with intensive and repeated 
exposure. The patient remains severely anxious, with ongoing cravings for alcohol and cannabis. The 
patient has undergone a previous course of PHP at the same facility, without adequate control of his 
symptoms.  
    With regard to treatment acceptance and engagement, the records support a score of 3. The patient has 
some variability, hesitation, or uncertainty in acceptance or understanding of his illness and disability. 
He has limited desire or lacks confidence to change despite intentions to do so, particularly with respect 
to his substance use disorder.   
 
Thus, the patient has a total score of 24. The records support a 4 in terms of functional status and 
comorbidity. In this case, the recommended level of care is medically monitored residence-based 
services. With the functional impairment and comorbidity noted, the patient meets LOCUS 5b extended 
stay criteria. Therefore, residential behavioral health from 9/7/22 through discharge was and is 
medically necessary for the treatment of this patient.