Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for all or any of the requested psychiatric residential treatment center (RTC) services provided at Newport Academy from August of 2021 forward.At issue in this case is whether all or any of the requested psychiatric residential treatment center (RTC) services provided at Newport Academy from August of 2021 forward were and are medically necessary to treat the patients medical condition 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 services provided from August of 2021 forward. With regard to risk of harm, the records support a score of 4. The patient has passive suicidal ideation with various plans but no current intent. Additionally, the patient had at least one aborted suicide attempt in the last year, and the patients mother found a gun in his car.In terms of function, the records support a score of 4. The patient avoids all social interactions and was fully withdrawn and isolated prior to admission to RTC with conflicted family relationships and no other relationships. The patient wasnt working and not in school.With regard to comorbidity, the records support a score of 3. The patient frequently has food aversion and nausea, which is worsened by anxiety. The patient treats this with cannabis, which then has a negative effect on his mood.In terms of level of stress of the recovery environment, the records support a score of 4. The patients closest family relationship was with his grandmother, who died in 2019. The patient isolates himself to avoid stressors but is unable to make progress this way.With regard to level of support of the recovery environment, the records support a score of 4. The patient is socially isolated. The patient does not access support from his family and does not have further supports outside his family.In terms of treatment and recovery history, the records support a score of 4. The patient has been in outpatient treatment since 2020 but without optimal control of his symptoms.With regard to engagement, the records support a score of 4. The patient is passive and disengaged in treatment. The patient also avoids contact with and use of treatment resources if left to his own devices.These findings give the patient a composite score of 27, which is consistent with medically monitored residence-based services or RTC. Per LOCUS, the patients scores of 4 for risk of harm and functional status also support treatment at Level 5 medically monitored residence-based services level of care. The patient has co-occurring substance use and mental health disorders that are both active and interact to seriously impede ability to enter recovery as well as great difficulty developing relationships with or using an available sources of support. Additionally, RTC services provided from August of 2021 forward were and are in accordance with the generally accepted standards of mental health and substance use disorder care. Moreover, RTC services provided from August of 2021 forward were and are clinically appropriate in terms of type, frequency, extent, site, and duration. RTC services provided from August of 2021 forward 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, the requested psychiatric residential treatment center (RTC) services provided at Newport Academy from August of 2021 forward 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.