Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for admission to residential treatment center (RTC) level of care, six months of RTC services, or 120 days of partial hospitalization program (PHP) services or 90 days of PHP services.There are several issues in this case:Is admission to residential treatment center (RTC) level of care to treat the enrollees mental health or substance use disorder, medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below?1.If yes, is six months of RTC services to treat the enrollees mental health or substance use disorder, medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below?2.If no, is admission to partial hospitalization program (PHP) level of care to treat the enrollees mental health or substance use disorder, medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below?a.If yes, are 120 days of PHP services to treat the enrollees mental health or substance use disorder, medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below?b.If 120 days PHP are not medically necessary, are 90 days of PHP services to treat the enrollees mental health or substance use disorder, medically necessary as defined in Health and Safety code section 1374(a)(3)(A) set forth below?Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.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, this patient meets criteria for Level 5 services, which are medically monitored residential treatment center services.With regard to risk of harm, the records support a score of 4. The patient has a recent pattern of excessive substance use resulting in loss of self-control and clearly harmful behaviors with no demonstrated ability to abstain from use. He engages in unprotected sex with multiple high-risk partners. The patient has a history of prior hospitalizations for SI.In terms of function, the records support a score of 4. The patient has an inability to perform close to usual standards in work, parenting, or other obligations, and these responsibilities may be completely neglected on a frequent basis or for an extended period of time. The patient is at risk of losing his job, his house, and his marriage/relationship with his son.With regard to comorbidity, the records support a score of 4. The patient has psychiatric symptoms that are disabling and which interact with and seriously impair his ability to recover from any co-occurring substance use disorder. This patient is noncompliant with his psychotropic medications and reports frequent SI. The records document a continual pattern of methamphetamine binges followed by depressive periods with SI.In terms of level of stress of the recovery environment, the records support a score of 4. The patient feels that he is about to lose his job and his home. The patient reports that he has been unable to maintain abstinence for any significant period of time and feels hopeless.With regard to level of support of the recovery environment, the records support a score of 3. The provider reports that the patients resources may be only partially utilized, even when available. The patient has professional support services through the Health Plan, but he is unable to stay sober during days in which he is not in a structured program.In terms of treatment and recovery history, the records support a score of 4. The patients previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. This patient was recently in PHP and relapsed during the program. The patient reports multiple prior treatment attempts since 2008. His longest period of abstinence was 100 days.With regard to engagement, the records support a score of 3. The patient has limited desire or lacks confidence to change despite intentions to do so. The patient feels hopeless about his ability to achieve sobriety with regard to his methamphetamine addiction. He has had multiple relapses despite intensive outpatient treatment and partial hospitalization program participation.These findings give the patient a composite score of 26, which is consistent with Level 5 services, or medically monitored residential services. Therefore, admission to RTC level of care is medically necessary for the treatment of this patient. The LOCUS guidelines do not specify definitive lengths of treatment, as the facilities are supposed to complete individualized treatment plans for each patient. Therefore, six months of RTC services are not medically necessary for treatment of the patients medical condition. In this patients case, admission to RTC level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the admission to RTC level of care is clinically appropriate in terms of type, frequency, extent, site, and duration. Moreover, admission to RTC level of care is not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.