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

he patient was diagnosed with bulimia and major depressive disorder. The patient was admitted to a partial hospitalization program (PHP). The patient had previously been treated in a residential treatment program (RTC). The patient reported a history of cutting her arms and legs. The patient denied any symptoms of psychosis. The patient endorsed food restriction, binge-eating, self-induced emesis, and a history of excessive exercise. Patient reported a history of eating disorder symptoms for several years. The patient was living with parents at the time of the PHP admission, and reported a close relationship with parents. Patient denied active suicidal thoughts and denied current self-harm thoughts. The patient was noted to have an improved mood with significantly diminished thoughts of self-harm. Patients weight was noted to be 114% of their ideal body weight and meal plan compliance was 95%. The patient has requested reimbursement for PHP services provided by Eating Disorder Center for California. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether PHP services provided by Eating Disorder Center for California were medically necessary for the treatment of the patients medical condition. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrist, is a level of care assessment tool widely used by behavioral health managers and clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include; (1) risk of harm; (2) functional status; (3) comorbidity; (4) recovery environment; (5) level of support; and (6) treatment and recovery history. For risk of harm, the patients score is 2, due to a lack of current suicidal ideation or current self-harming behaviors. The patient reported a history of self-harm in February 2019. For functional status, the patients score is 2, due to an overall good functional level with appropriate activities of daily living. For comorbidity, the patients score is 2, due to overall medical stability, no chronic medical issues and no active substance use. Patient was diagnosed with major depressive disorder. For recovery environment level of stress, the patients score is 2, due the patient reporting they were unemployed. For recovery environment level of support, the patients score is 2, due to family support and availability of treatment resources. For treatment and recovery history, the patients score is 2, due to her success in the recent RTC program. For engagement and recovery status, the patients score is 2, due to her cooperation in treatment and insight into her need for treatment. The patients composite LOCUS score is 14, which correlates with a treatment intensity level of low intensity community-based services. The medical evidence does not support the services at issue in this clinical setting. Therefore, PHP services provided by Eating Disorder Center for California were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were 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.