Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the RTC services provided at Skyland Trails (in Atlanta, Georgia). 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. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to suicidal ideation without any intent or plan and without past history of suicide attempts. The patient reported suicidality with worsening of his symptoms. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient had to drop out of college due to the intensity of his anxiety symptoms and difficulty functioning, moving back home and reported being quite isolated. With regard to comorbidity, the records support a score of 1. The patient had no medical or psychiatric comorbidities. In terms of level of stress of the recovery environment, the records support a score of 4.  The patient had a highly stressful environment due to feeling overwhelmed in meeting demands and obligations, leaving school and struggling once back home.  With regard to level of support of the recovery environment, the records support a score of 3 as the patient relied entirely on his parents and his brother for social support, isolating himself from others.  In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible response to treatment as despite continued attempts at intensive treatment in the outpatient setting since high school, the patients anxiety and mood continued to worsen.  With regard to treatment acceptance and engagement, the records support a score of 4. The patient seemingly sought help at the RTC but was reported to be focused on discharge and easily distracted throughout treatment, having difficulty accepting responsibility for his own recovery.Thus, the patient has a total score of 24. The records support a 4 in terms of functional status. In this case, the recommended level of care is medically monitored residence-based services. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, RTC services provided at Skyland Trails (in Atlanta, Georgia) were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.