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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) trauma residential treatment center, (2) testing for ADHD, (3) testing for sensory processing disorder (SPD), and (4) testing for auditory processing disorder (APD). At issue is whether (1) trauma residential treatment center 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 significant risk of harm due to ongoing intermittent suicidal ideation, in the context of her depressive symptoms, without intent or plan, and without a history of self-harm behaviors. In terms of functional status, the records support a score of 2. The documentation noted mild impairment due to some insomnia and complicating medical conditions. The records noted that the patient was employed, although on leave, and handling household and parenting responsibilities. The patient is experiencing some problems in interpersonal interactions, with increased irritability, hostility or conflict, but is able to maintain some meaningful and satisfying relationships. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of major depressive disorder, autism spectrum disorder, trauma and stressor related disorder, and numerous psychiatric conditions that require medical monitoring and may adversely impact the course of the presenting disorder. In terms of level of stress of the recovery environment, the records support a score of 2.  The patient has a mildly stressful environment due to some perceived performance pressure at work, leading to increased anxiety.  With regard to level of support of the recovery environment, the records support a score of 2 as the patient has multiple medical and professional supports in place and her level of functioning allows her to effectively engage with her supports. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, due to continued, ongoing symptoms that have not responded significantly to medications, transcranial magnetic stimulation (TMS), or therapies. The patients previous or current treatment is not achieving complete remission of symptoms or optimal control of symptoms. With regard to treatment acceptance and engagement, the records support a score of 2. The patient has significant understanding of and acceptance of her illness and its effect on her function. She appears to have trusting relationships with several, but not all, of her providers.Thus, the patient has a total score of 17. In this case, the recommended level of care is high intensity community-based services. Therefore, (1) trauma residential treatment center is not medically necessary for the treatment of this patient.At issue is whether (2) testing for attention-deficit/hyperactivity disorder (ADHD) is medically necessary for the evaluation of this patient.Austerman reports that the diagnostic procedure for ADHD involves clinical interview, clinical examination, review of past medical records, and collateral history. There are no biological or psychological tests that can diagnose ADHD. In this case, given that the patient has previously undergone clinical evaluation for ADHD and was not diagnosed with ADHD, the requested service is not medically indicated. Therefore, (2) testing for ADHD is not medically necessary for the evaluation of this patient.At issue is whether (3) testing for sensory processing disorder (SPD) is medically necessary for the evaluation of this patient.The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) does not include a diagnosis for sensory processing disorder. The patients presumed sensory differences are subsumed within her diagnosis of autism spectrum disorder, meaning that since the patient already has an autism diagnosis, any sensory issues would be accepted without needing to test separately for these. Therefore, (3) testing for SPD is not medically necessary for the evaluation of this patient.At issue is whether (4) testing for auditory processing disorder (APD) is medically necessary for the evaluation of this patient.The DSM-5 does not recognize auditory processing disorder. In this case, the records note that the patient has previously undergone psychological testing that included an evaluation for possible receptive language disorder. The patients verbal comprehension index (VCI) and perceptual reasoning index (PRI) scores were both noted as being within the normal range. Therefore, (4) testing for APD is not medically necessary for the evaluation of this patient.