Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent 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 moderate risk of harm (score 3). The records document that the patient has denied suicidal ideation while in RTC, but a previous suicide attempt was in the context of severe psychosis. In addition, the patient continues to minimize the psychotic symptoms and is internally preoccupied, putting the patient at risk for impulsive self-harm in the context of continued psychotic symptoms. There is no active suicidal ideation, but extreme distress and a history of suicidal behavior exists. For dimension 2, the patient has demonstrated serious functional impairment (score 4) due to inability to function in school and continued complaints about the difficulty functioning even while at RTC. The provider noted that the patient paces around and is restless due to anxiety even while at RTC and has trouble engaging in appropriate interpersonal interactions. There is documentation of inability to perform close to usual standards in school and other obligations and these responsibilities may be completely neglected on a frequent basis or for an extended period of time. For dimension 3, the patient has significant comorbidities (score 3) given a history of asthma, in addition to an abnormal chest x-ray while in the RTC. The patient is awaiting a computed tomography (CT) of the chest to work-up this abnormality. Additionally, the patient has a lot of trouble with interpersonal issues due to the autism spectrum disorder. Medical conditions exist, which may require significant medical monitoring. For dimension 4A, the patients recovery environment is moderately stressful (score 3). The records note that the patient has experienced a deterioration in interpersonal interactions and ability to function. The records document recent important loss or deterioration of interpersonal circumstances. For dimension 4B, the patients recovery environment provides limited support (score 3) given the patients reliance entirely on the father for social support and has a conflicted relationship with mother. A few supportive resources exist in the patients current environment and may be capable of providing some help if needed. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4). The patient has undergone numerous hospitalizations and has exhibited trouble functioning outside of a structured setting. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 6, the patient has demonstrated limited engagement and recovery (score 3) considering the patients difficulty trusting the intentions of the treatment providers and understanding interpersonal interactions with peers. The records indicate that the patient relates to treatment with some difficulty and establishes few, if any, trusting relationships. These findings give the patient a composite score of 23, which is consistent with Level 5 medically monitored residence-based services. Per LOCUS, the patients scores of 4 for functional status also support treatment at Level 5 medically monitored residence-based services. Additionally, in terms of length of treatment in a medically monitored residential program, for which the patient is appropriate and in which treatment is medically necessary based on the LOCUS criteria, the patient meets criteria for intermediate stay, level 5B, with expected length of stay not exceeding 60 days due to the serious impairment in role functioning at school and ongoing significant disturbance in interpersonal skills and interactions. 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.