Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for partial hospitalization program (PHP) level of care. Findings:  The physician reviewer found that (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. With regard to risk of harm, the records support a score of 2. The patient had a remote history of suicide attempts. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to challenges with poor food intake related to anorexia.With regard to comorbidity, the records support a score of 3. The patient has major comorbidity due to her significant food restriction, decreased weight, and medical concerns such as past cardiac events, related to her anorexia. The patient also reports social anxiety.In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to being unemployed. With regard to level of support of the recovery environment, the records support a score of 2 as the patient has support from clinicians.In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The records noted that the patient demonstrated ambivalence with recovery and vacillates between shutting down through sessions and leaving groups but then emailing the treatment team to express herself. Thus, the patient has a total score of 20. In this case, the recommended level of care is medically monitored community-based services. In this patients case, PHP level of care is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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. Therefore, PHP level of care is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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.