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. 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. For dimension 1, the patient has been at serious risk of harm (score 4). The records document that the patient has denied any suicidal ideation or homicidal ideation. However, the patient has been paranoid throughout his RTC stay, and his ability to care for himself adequately and be aware of his environment in a reality-based way has been compromised. For dimension 2, the patient has demonstrated serious functional impairment (score 4) due to his inability to work. The patient has been significantly withdrawn and avoiding of all social interactions due to his paranoid thoughts and anxiety. For dimension 3, the patient has major co-morbidity (score 4) given his numerous medical issues, including diabetes mellitus and hypertension, and his cardiac status needs to be closely monitored due to issues with his QTc with antipsychotics. Medical conditions exist, or have a very high likelihood of developing, which may require intensive, although not constant, medical monitoring. For dimension 4A, the patients recovery environment has been moderately stressful (score 3). The provider noted that the patient perceives continued danger in his environment. For dimension 4B, the patients recovery environment has provided minimal support (score 4). The records document that the patient depends heavily on his mother for emotional support, and he otherwise has little social support. Very few actual or potential sources of support are available. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4). Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient has exhibited limited engagement and recovery (score 3) due to his great deal of trouble in accepting his illness and difficulty using available resources independently. These findings give the patient a composite score of 26, which is consistent with medically monitored residence-based services or RTC. Additionally, scores of 4 in risk of harm and level of functioning supports treatment at the RTC level of care. 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. Furthermore, the RTC services RTC services provided were and 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. All told, the RTC 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.