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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage 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 4. The patient had a serious risk of harm, due to ongoing passive suicidal ideation. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflicted relationships with family and others but an ability to maintain control of aggressive or abusive behaviors. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of an eating disorder, addictive behavior, and worsening psychiatric symptoms.In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has a highly stressful environment due to a family history of abuse, causing serious disruption of the family and leading to severe conflict. The patient continued to feel unsafe with his family. With regard to level of support of the recovery environment, the records support a score of 4 as the patient has few actual or potential sources of support due to a lack of trust in his family, given his history of abuse. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, without diminished suicidality or improvement in function despite 90 days of inpatient treatment.With regard to treatment acceptance and engagement, the records support a score of 3. The patient has limited ability to accept his own role in his dysfunctional relationships and engagement with the world around him and lacks the confidence to change. Thus, the patient has a total score of 25. The records support a 4 in terms of risk of harm. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm noted, the patient meets LOCUS 5b extended stay criteria. This is consistent with the level of care that the patient has been and is receiving at the RTC. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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 and are medically necessary for the 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.