Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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 met the criteria for RTC services. For dimension 1, the patient was at moderate risk of harm (score 3). The records document that the patient was bingeing daily prior to RTC, isolating, and showed evidence of self-neglect and dehydration and decrease in ability to care for oneself in current environment. For dimension 2, the patient demonstrated serious impairment (score 4) due to great difficulties functioning prior to RTC, bingeing daily and isolating completely from others. The patient was not able to work prior to RTC. The patient engaged in significant withdrawal and avoidance of almost all social interaction. For dimension 3, the patient has major co-morbidity (score 4) given her numerous serious medical issues, including past stroke, unstable hypertension, and lower extremity edema, all worsened by her anxiety and eating disorder. The patients conditions were difficult to manage during RTC even with twice daily vital sign monitoring. 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 was moderately stressful (score 3). The provider noted that the patient had constant triggers for eating disorder outside of RTC with deteriorating health as her eating disorder worsened and she engaged in significant alienation from social interactions. There was significant discord or difficulties in family or other important relationships or alienation from social interaction. For dimension 4B, the patients recovery environment was supportive (score 2) since the patient depended heavily on her father with whom she has a strained relationship. Although the patient has some friends, she isolated herself completely prior to RTC admission. Supportive resources are not abundant but are capable of and willing to provide significant aid in times of need. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4). The patient has engaged in outpatient, RTC and partial hospitalization program (PHP) levels of care without sustained remission of symptoms. Thus, 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 shown limited engagement and recovery (score 3) due to some variability hesitation, or uncertainty in acceptance of her illness and disability with limited desire to change despite intentions to do so, even while at RTC. These findings give the patient a composite score of 23, which is consistent with medically monitored residence-based services. Additionally, the patients score of 4 in level of functioning necessitates treatment at 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 were 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 medically necessary for 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.