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. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm due to suicidal ideation, a history of self-injurious behavior and a suicide attempt by overdose.  In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to the severity of her symptoms. The patient has been isolating with significant withdrawal from almost all social interactions, easily becoming dysregulated even while in treatment.  With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to the presence of misophonia, which triggers her dysregulation and constantly overstimulates her, and substance use. The records noted that the patient left the RTC twice to search for alcohol and drugs. In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has a highly stressful environment as she has been unable to function since the start of the pandemic, isolating herself at home and feeling triggered by her conflictual relationship with her family. The records noted that the patient had been struggling since her parents divorce in 2016.With regard to level of support of the recovery environment, the records support a score of 4 as the patient has limited support, isolating herself completely and with a conflictual relationship with family.  In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management due to a history of inpatient hospitalizations and a previous RTC stays without benefit.With regard to treatment acceptance and engagement, the records support a score of 3. The patient has some variability and hesitation in accepting and trusting treatment providers, does not use available resources independently, and has limited ability to accept responsibility for her recovery.Thus, the patient has a total score of 27. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm, functional impairment, and comorbidity noted, the patient meets LOCUS 5b extended stay criteria. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and 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. Therefore, RTC services were and are medically necessary for the 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.