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

Findings:  The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for a 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 3. The patient has a significant risk of harm, due to a history of suicidal ideation and self-injurious behavior and current passive suicidal ideation and urges to self-harm with self-harm behavior.  In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient had to drop out of school due to trouble functioning, has been neglecting physical hygiene and not showering daily, isolating, and in conflictual relationship with fer parents. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of drinking prior to admission to the RTC, and the records did not note that the patient has engaged in addiction recovery programming while at the RTC.  In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment as has recently been unable to manage the stress and pressures of school and has had to withdraw and return home, where the relationship with parents is conflictual and isolates.  With regard to level of support of the recovery environment, the records support a score of 4 as the patient has isolated from all social supports outside of parents and has a conflictual relationship with parents.  In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management. The patient was recently hospitalized psychiatrically for suicidal ideation with plan and continues to struggle significantly with mood and anxiety without the ability to maintain gains made outside of a structured treatment setting. Thus, the patient has a total score of 24. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment noted, the patient meets Level 5b extended stay criteria.  This is consistent with the level of care that the patient was 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 services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.