Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is 62-year-old male with a history of major depressive disorder, generalized anxiety 
disorder, cannabis use disorder, alcohol use disorder, hypothyroidism, and hypertension. The 
physician reviewer found that 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 meets the criteria for RTC services provided from 12/15/22 
through 12/18/22.  For dimension 1, the patient was at a moderate risk of harm (score 3), due to 
having no history of suicide attempts, but a history of daily suicidal ideation. The records 
document the patient being in extreme distress as well as a history of excessive use of substances 
resulting in potentially harmful behaviors. For dimension 2, the patient demonstrated serious 
functional impairment (score 4). The providers records document a significant withdrawal and 
avoidance of almost all social interaction. The patient was unable to work due to his symptoms. 
Additionally, the patient had estrangement from his family and significant withdrawal and 
isolation from almost all social interactions. For dimension 3, the patient had significant co-
morbidity (score 3). The patient had significant substance use with detrimental effects, which has 
been  temporarily  arrested  through  detoxification  and  now  RTC.  The  patient  has  also  had 
diagnoses of hypothyroidism and hypertension, which can influence his depressive symptoms 
and  may  require  significant  medical  monitoring.  For  dimension  4A, the  patients  recovery 
environment  was  highly  stressful  (score  4).  The  providers  records  note  that  the  patient 
experienced difficulty avoiding exposure to active users and other pressures to partake in alcohol 
or drug use. The patient is estranged from his family and was living with a friend who uses 
substances  daily.    For  dimension  4B,  the  patients  recovery  environment  was  minimally 
supportive (score 4). The provider notes report very few actual or potential sources of support 
were available. The patient had no social support other than his roommate. For dimension 5, this 
patient has exhibited poor response to treatment and recovery management (score 4). The 
providers records document that previous treatment had not achieved complete remission of 
symptoms or optimal control of symptoms even with intensive and/or repeated exposure. The 
patient had been previously hospitalized for mental health reasons and had completed RTC in 
the past. The patient had been in detoxification six times during the last several years without 
remission of his symptoms. For dimension 6, the patient has shown limited engagement and 
recovery (score 3). The patient was actively engaged in treatment but lacked confidence to 
change despite intentions to do so because of his past inability to change. These findings give the 
patient a composite score of 25, which is consistent with medically monitored residence-based 
services. Further, a score of 4 in level of functioning requires treatment at this higher level of care 
(RTC). Additionally, in terms of length of stay, the patient meets criteria for level 5B: moderate 
intensity intermediate stay residential treatment programs with length of stay up to 60 days due 
to serious impairment in expected role functioning in work, school and home. Moreover, the RTC  services are in accordance with the generally accepted standards of mental health and substance 
use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, 
and not primarily for the convenience of the patient or provider. For these reasons, RTC services 
at A Better Life Recovery provided from 12/15/22 through 12/18/22 were medically necessary 
for treatment of this patient.