Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 20-year-old female with generalized anxiety disorder, sedative/hypnotic/anxiolytic dependence, alcohol dependence, cannabis dependence, borderline personality disorder and major depressive disorder. She has requested reimbursement for partial hospitalization program services provided from 12/08/20 through 12/10/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. 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 partial hospitalization program services. In terms of risk of harm, the records support a score of 4. This dimension assesses potential for harm to self or others. This patient was admitted to residential treatment following a suicide attempt and continued to have passive suicidal ideation through much of her treatment. Therefore, there was a serious risk of harm given her past history of carrying out suicidal behavior. With regard to function, the records support a score of 3. This dimension assesses the degree to which a person is able to fulfill social responsibilities and maintain physical functioning and capacity for self-care. The patient was expelled from college for substance use on campus prior to admission to residential treatment. She continued to have conflictual relationships with those around her and was quite isolated and withdrawn. In terms of 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 has had recent substance use with clearly detrimental effects on her presenting disorder. With regard to 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 has had a recent romantic relationship break-up and has been expelled from college. She has had significant discord in her family relationships. In terms of level of support of the recovery environment, the records support a score of 3. This dimension assesses the presence of family and social support to augment the recovery environment. Although the patient cites a large friend group, she does not actually name these friends as supports. Her only real support is her mother, with whom she has a conflictual relationship. With regard to treatment and recovery history, the records support a score of 3. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. In this case, previous treatment had not achieved complete remission of symptoms or optimal control of symptoms despite having been hospitalized psychiatrically in 2020 and recent completion of residential treatment. In terms of engagement, the records support a score of 3. This dimension assesses a patientas understanding of his or her illness and treatment, and ability and willingness to engage in the treatment process. This patient has had variability and hesitation in her engagement in treatment and has some difficulty accepting responsibility for her recovery. Thus, the patient has a composite score of 22, which is consistent with medically monitored community-based services or partial hospitalization program level of care. Of note, the patientas score of 4 in terms of risk of harm supports residential treatment. Thus, there is sufficient support for partial hospitalization program level of care in this setting. Therefore, partial hospitalization program services provided from 12/08/20 through 12/10/20 were medically necessary for the treatment of this patient.