Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that 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 RTC services.For dimension 1, the patient has been at moderate risk of harm (score 3). The records document that the patient denies any suicidal ideation or past suicide attempts but has a history of substance use resulting in potentially harmful behaviors in the past but without recent episodes. Additionally, the patient has demonstrated self-neglect and a decrease in their ability to care for themselves prior to admission to RTC as well as throughout the admission. There is some evidence of self-neglect and decrease in ability to care for oneself in current environment. For dimension 2, the patient has demonstrated serious functional impairment (score 4) since the patient has been unable to attend school or work due to severe symptoms. The patient is isolative with significant withdrawal from almost all social interactions and consistent failure to maintain personal hygiene. The patient has shown consistent failure to maintain personal hygiene, appearance, and self-care near usual standards. For dimension 3, the patient has significant comorbidities (score 3) given the recent substance use that has aggravated the patients anxiety and psychotic symptoms but has been temporarily arrested. There is report of recent substance use which has had clearly detrimental effects on the presenting disorder, but which has been temporarily arrested through use of a highly structured or protected setting or through other external means. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The records document conflict between the patient and their father and break-up with their boyfriend, which the patients father indicated was not actually part of the patients reality. The patients psychotic reality is stressful even if their actual reality presents as more stable. There is significant discord and difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment provides limited support (score 3). The provider noted that the patient has isolated themselves from most social supports. Despite a seemingly supportive relationship with parents, the patient describes significant conflict with their father. Overall, a few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4). The patient was hospitalized psychiatrically twice in the last year in addition to PHP and IOP with continued significant psychiatric symptoms and inability to function. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 6, the patient has shown minimal engagement and recovery (score 4). The provider charted that the patient is distracted in groups, leaves repeatedly, and paces or declines to attend groups. The patient has not accepted any responsibility for recovery. The records indicate that the patient avoids contact with and use of treatment resources if left to own devices. These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services. In addition, the patients score of 4 for functional status supports Level 5 medically monitored residence-based services. Moreover, in terms of length of stay, the patient meets criteria for level 5B moderate intensity intermediate stay residential treatment programs due to significant disturbance in interpersonal skills and interactions as well as serious impairment in expected role functioning at home, school and work. Furthermore, 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, the RTC level of care services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.