Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 23-year-old female with major depressive disorder, generalized anxiety disorder, 
and  cannabis  use  disorder.  The  patient  has  requested  reimbursement  for  mental  health 
residential treatment center services provided from 12/01/21 through 12/06/21. 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 met the criteria for residential treatment center services 
provided 12/01/21 to 12/06/21. For dimension 1, risk of harm, the records support a score of 3. 
This dimension assesses potential for harm to self or others.  The patient was admitted to the 
residential treatment center with passive suicidal ideation, frequent self-injurious behavior and 
poor coping skills and history of self-aborted suicide attempt. For dimension 2, functional status, 
the records support a score of 4. This dimension assesses the degree to which an individual is 
able to fulfill social responsibilities, interacts with, maintain physical functioning and capacity for 
self-care. The patient was unable to attend school or work due to severe symptoms. The patient 
was withdrawn socially from almost all social interactions. For dimension 3, comorbidity, the 
records support a score of 3. This dimension assesses potential complications in the course of 
treatment due to acuity or disability related to co-occurring medical illness, substance use 
disorder, or psychiatric disorder. The patient had used cannabis daily prior to admission to the 
residential treatment center, with significant negative impact on her psychiatric symptoms. For 
dimension 4A, level of stress of the recovery environment, the records support a score of 3. This 
dimension assesses the stressors in the environment, social circumstances, and interpersonal 
relationships.  The patient had easy access to cannabis at home and had a recent break-up with 
her boyfriend of three years, causing increased stress. For dimension 4B, level of support of the 
recovery environment, the records support a score of 4.  This dimension assesses the presence 
of family and social support to augment the recovery environment. The patient was isolated from 
friends, had recently broken up with her boyfriend and isolated herself to her room much of the 
day, relying fully on her parents for support, although she had difficulty reaching out to even her 
parents. For dimension 5, treatment and recovery history, the records support a score of 4. This 
dimension assesses how past experiences with treatment and recovery might indicate how the 
patient might respond in the future. The patient was in outpatient treatment with inconsistent 
adherence  to  medications  prior  to  residential  treatment,  but  without  optimal  control  of 
symptoms. For dimension 6, engagement, the records support a score of 3. This dimension 
assesses a patients understanding of his or her illness and treatment, and ability and willingness 
to engage in the treatment process. The patient appeared motivated in the residential treatment 
center but had trouble engaging with some therapists and coped with stress in treatment with 
self-injury. These findings give the patient a composite score of 24, which is consistent with 
medically monitored residence-based services or residential treatment. Additionally, the patient 
scored a 4 in functional status, which supports residential treatment level of care. Therefore,  mental health residential treatment center services provided from 12/01/21 through 12/06/21 
were medically necessary for the treatment of this patient.