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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) 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. Applying the LOCUS framework, the patient does not meet the criteria for the PHP services.For dimension 1, the patient has been at moderate risk of harm (score 3) since he has no suicidal ideation, but he has engaged in repeated self-injurious behavior that is impulsive. Additionally, there is some evidence of self-neglect given his difficulty maintaining his nutrition and his activities of daily living. History of chronic impulsive suicidal behavior or threats, but current expressions do not represent significant change from usual behavior. Also, there is some evidence of self-neglect and decrease in ability to care for oneself in current environment. For dimension 2, the patient has exhibited moderate functional impairment (score 3). The records document that the patient has become withdrawn and isolated. He has been struggling with his sleep and eating habits as well as his activity level. He has significant trouble in maintaining work performance and caring for his child. This supports significant disturbances in physical functioning such as sleep, eating habits, activity level, or sexual appetite, but without a serious threat to health. In addition, there is significant deterioration in ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. For dimension 3, the patient has no comorbidities (score 1) due to no medical or substance use comorbidity. There is no evidence of medical illness, substance use disorders, or psychiatric disturbances apart from the presenting disorder. For dimension 4A, the patients recovery environment has been mildly stressful (score 2) considering the patients pressures to succeed that are self-imposed and his feelings of isolation and alienation. The patients ex-spouse is able to take care of their child when he feels unable to do so, and the patient has no transitions in school or work, affecting his presentation. Presence of some ongoing or intermittent interpersonal conflict, alienation, or other difficulties. For dimension 4B, the patients recovery environment has been supportive (score 2) since the patient can rely on his ex-spouse to take care of their child, and his sister is a support for him. The patient is established with an outpatient psychiatrist, therapist, and life coach, who provide support outside of the PHP. Professional supports are available and effectively engaged. For dimension 5, the patient has demonstrated moderate or equivocal response to treatment and recovery management (score 3). The patient reportedly has experienced a prolonged struggle with mood and trauma-based symptoms, despite treatment with electroconvulsive therapy. He was treated in the intensive outpatient program (IOP) level of care at the end of 2019 and beginning of 2020 and was able to maintain moderate stability until August 2020. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has shown limited engagement and recovery (score 3). The provider noted that the patient repeatedly grapples with his illness and lacks the confidence to change despite his intentions to do so. The patient has shown a limited ability to accept responsibility for recovery and has trouble utilizing resources independently. The patient lacks confidence to change despite intentions to do so. These findings give the patient a composite score of 17, which is consistent with high intensity community-based services. Therefore, the PHP services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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.