Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage 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 meets the criteria for RTC services. For dimension 1, the patient has been at serious risk of harm (score 4) due to an interrupted suicide attempt just prior to admission to inpatient and RTC. The records document current suicidal ideation with expressed intentions and a history of carrying out such behavior but without means for carrying out the behavior, or with some expressed inability or aversion to doing so. For dimension 2, the patient has shown serious functional impairment (score 4) given his ongoing conflict with his wife, family, and coworkers, as well as his recent affairs and interrupted suicide attempt. There is evidence of serious decrease in the quality of interpersonal interactions with consistently conflictual or otherwise disrupted relations with others, which may include impulsive, aggressive, or abusive behaviors. For dimension 3, the patient has minor co-morbidity (score 2) considering his chronic pain issues and palpitations. The patients medical conditions are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The records document that  the patient is on the verge of divorce from his wife after his infidelity was discovered and she is not allowing him back in the family home. The patient also has a highly stressful work situation. The records document serious disruption of family and social milieu. For dimension 4B, the patients recovery environment provides minimal support (score 4) since the patients relationship with his wife and coworkers are currently strained. There are very few actual or potential sources of support available. For dimension 5, the patient has exhibited moderate or equivocal response to treatment and recovery management (score 3) due to his inability to participate in outpatient treatment and incomplete remission of symptoms in inpatient treatment just prior to RTC admission. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient has demonstrated limited engagement and recovery (score 3) due to some variability, hesitation, or uncertainty in acceptance of his illness. The patient also does not use available resources independently or only in cases of extreme need. These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services. Additionally, 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. In addition, scores of 4 in risk of harm and level of functioning necessitates treatment at his higher level of care. Moreover, the RTC services were and are 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. For these reasons, the RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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.