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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided by McLean Hospital from 7/17/21 through 8/14/21.At issue in this case is whether residential treatment center (RTC) services provided by McLean Hospital from 7/17/21 through 8/14/21 were and/or are medically necessary to treat the patients medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.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. Applying the LOCUS framework, the patient met the criteria for RTC services provided from 7/17/21 through 8/14/21. With regard to risk of harm, the records support a score of 3. The patient has had suicidal ideation and self-injurious behavior in the past and now presents with hopelessness, inability to function due to compulsions, and urges to self-harm.In terms of function, the records support a score of 4. The patient finished college in May 2020 and has been unable to function enough to work or leave the home much. The patient relies entirely on his parents and spends much of the day in the throes of his compulsions, rocking and checking. The patient is withdrawn from social interactions due to these symptoms.With regard to comorbidity, the records support a score of 3. The patients learning disability has significantly complicated the patients treatment for OCD, causing the team at McLean Hospital to alter their recovery protocol for the patient and resulting in a longer period of treatment.In terms of level of stress of the recovery environment, the records support a score of 3. Although the patients home environment is not stressful, the world outside his home is quite stressful for him. The records indicate that the patient has had difficulties functioning outside the home, isolating himself and feeling hopeless in his inability to meet the obligations of a potential job or social interactions due to his intense compulsions and rituals.With regard to level of support of the recovery environment, the records support a score of 4. The patients parents are his only source of support, and his parents are at a loss as to how to help the patient given his refractory symptoms and inability to self-soothe without rocking for hours.In terms of treatment and recovery history, the records support a score of 5. Even the outpatient program in a specialized clinic for OCD was unable to reduce the patients symptoms. The patient has struggled like this for many years, although his symptoms have worsened recently in the context of the pandemic and social isolation.With regard to engagement, the records support a score of 3. Given his learning disability and significant symptoms, the patient has difficulty using his available resources independently and is unable to accept responsibility for his recovery.These findings give the patient a composite score of 25, which is consistent with medically monitored residence-based services or RTC. Per LOCUS, the patients score of 4 for functional status also supports treatment at Level 5 medically monitored residence-based services level of care. For these reasons, the RTC services provided by McLean Hospital from 7/17/21 through 8/14/21 were and are medically necessary for treatment of this patient. 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 provided by McLean Hospital from 7/17/21 through 8/14/21 were and are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services were and 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.