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 at Olympia House. 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 a history of self-harm, significant substance use resulting in substance-induced psychosis, and homelessness.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the due to homelessness, substance abuse, and psychotic symptoms induced by substance-use.With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to the presence of uncontrolled substance use at a level that threatens his physical health and prevents recovery from his eating disorder. In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has a highly stressful environment due to having no social supports, being homeless, and a history of substance use. With regard to level of support of the recovery environment, the records support a score of 4 as the patient has a strained relationship with his mother, no other social supports, and isolates himself. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate or equivocal response to treatment, with minimal response to treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient has had challenges accepting his role in recovery, lacking the confidence to change. Thus, the patient has a total score of 26. In this case, the recommended level of care is medically monitored residence-based services. With the elevated risk of harm, functional impairment, and comorbidities noted, the patient meets LOCUS 5b extended stay criteria.  This is consistent with the level of care that the patient received and is receiving at the residential treatment center. 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 at Olympia House 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.