Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for residential treatment center services for a minimum of 30 days.At issue in this case is whether the requested residential treatment center services for a minimum of 30 days to treat the patients mental health or substance use disorder are 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, the patient met the criteria for RTC level of care. With regard to risk of harm, the records support a score of 5. The patient is unable to care for himself due to his severe depression and anxiety, deteriorating physically to the point of being diagnosed with failure to thrive. He is unable to manage ADLs without family support and has lost significant weight in the last few months.In terms of function, the records support a score of 5. The patient has no capacity for self-care, eating, drinking or bathing without family assistance and prompting to the point of his physical health deteriorating due to his neglect.With regard to comorbidity, the records support a score of 4. The patient has diabetes and hypertension, is not taking any medications for these illnesses, and his medical presentation was quite neglected on presentation, with hypernatremia due to severe dehydration and malnutrition.In terms of level of stress of the recovery environment, the records support a score of 4. The patient was a teacher but was unable to manage teaching from home due to his hoarding situation and was forced to retire in the spring, leaving him to deteriorate psychiatrically and physically.With regard to level of support of the recovery environment, the records support a score of 4. The patients family did not contact him for six months until they had the police check on him and found him in such a state where he was malnourished, dehydrated and with failure to thrive due to his depression and anxiety. They are unable to support the patient.In terms of treatment and recovery history, the records support a score of 4. The patient had no formal psychiatric history prior to his psychiatric admission in May 2021, and during that hospitalization, there was limited improvement in his ability to function. Since discharge, he stopped taking his medications and was not able to engage in any treatment, losing any gains made in the hospital.With regard to engagement, the records support a score of 4. The patient is guarded and has difficulty engaging in treatment and with providers.These findings give the patient a composite score of 30, which is consistent with medically managed residence-based services. This exceeds the level of care of RTC and actually qualifies the patient for inpatient level of care. Per LOCUS, the patients scores of 5 for risk of harm and function also support treatment at Level 6 for medically managed residence-based services level of care. In this patients case, RTC services for a minimum of 30 days are 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. Thus, residential treatment center services for a minimum of 30 days are medically necessary for the treatment of the patients medical condition.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.