Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for partial hospitalization program (PHP) services provided from 6/24/21 through 7/15/21.At issue in this case is whether PHP services provided from 6/24/21 through 7/15/21 were medically necessary to treat the patients medical condition 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, the patient met the criteria for PHP services provided from 6/24/21 through 7/15/21. With regard to risk of harm, the records support a score of 3. The patient has had suicidal ideation and self-injurious behavior, escalating in severity leading up to admission to PHP.In terms of function, the records support a score of 4. The patient has had a serious decrease in the quality of her interpersonal interactions with consistently conflictual relations and impulsive, aggressive behaviors.With regard to comorbidity, the records support a score of 1. The patient has no medical comorbidities.In terms of level of stress of the recovery environment, the records support a score of 3. The patient has had significant discord and conflict with her family, isolating herself even further in the context of the pandemic when she was already isolated.With regard to level of support of the recovery environment, the records support a score of 3. Although the patient's parents are invested in supporting the patient, she pushes them away and has significant conflict with them and is otherwise isolated.In terms of treatment and recovery history, the records support a score of 4. The patient has been in intensive outpatient treatment without improvement in symptoms and with continued decline. With regard to engagement, the records support a score of 3. The patient has limited ability to accept responsibility for her recovery and trouble forming trusting relationships.These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services or PHP. In this patients case, PHP 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. Moreover, 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, PHP services provided from 6/24/21 through 7/15/21 were medically necessary for treatment of the patients medical condition.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.