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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided by A Mission for Michael. 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 2. The patient has some potential for risk of harm, due to a history passive suicidal ideation dating back to the eighth grade. At the time of admission to the RTC, the patient denied suicidal ideation. The records did not note a history of suicide attempts, a history of self-harm other than a two-week period of scratching over a year earlier, or aggression. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment. Although the patient reports a decline in appetite and in the quality of duration of sleep, she continues to eat about two meals a day and to sleep for five hours nightly, rating the quality of the sleep as a six out of ten. The patient reported socially isolating and crying at work. The patients mother reported that the patient was binge eating. With regard to comorbidity, the records support a score of 2. The patient has minor comorbidity due to the presence of psychiatric diagnoses and co-occurring insomnia. 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 strained relationship with family members, and that she was taking a year off from college due to mental health.With regard to level of support of the recovery environment, the records support a score of 2 as the records note that the patient's family is actively supportive and participates in her treatment. In terms of resiliency and treatment history, the records support a score of 2. The patient has been working with an outpatient psychotherapist and psychiatrist for two months and started on antidepressant medications. However, given the brevity of prior treatment, it is too early to determine the patients response to this treatment. With regard to treatment acceptance and engagement, the records support a score of 2. The patient appears to have positive engagement as evidenced by her engagement with treatment providers, including self-disclosure and a desire for help. Thus, the patient has a total score of 16. In this case, the recommended level of care is low intensity community-based services. In this patients case, RTC level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, RTC services provided by A Mission for Michael were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.