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 endorsing suicidal ideation with a plan to cut his wrists in reaction to intense psychotic symptoms he was experiencing at admission. The patient had attempted suicide by cutting his wrists in the last two months. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment. The patient had a recent driving under the influence (DUI), was engaging in impulsive activities, reported shame and guilt from his substance use, and was unable to work due to his symptoms. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity due to the presence of recent alcohol and substance use with detrimental effects on the patients psychiatric symptoms, which was temporarily been arrested while at the RTC.  In terms of level of stress of the recovery environment, the records support a score of 3.  The patient has a moderately stressful environment due to easy exposure and access to alcohol and substances outside of treatment.  With regard to level of support of the recovery environment, the records support a score of 3 as the patient depends heavily on his mother but appears to be otherwise fairly isolated. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, as he has received treatment at inpatient, RTC, partial hospitalization program (PHP), and intensive outpatient program (IOP) levels of care without sustained remission of symptoms. With regard to treatment acceptance and engagement, the records support a score of 3. The patient has some variability in acceptance of his illness and limited ability to accept responsibility for his recovery and is not engaging in substance treatment and relapse prevention planning. Thus, the patient has a total score of 24. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care is medically monitored residence-based services. With the functional impairment and elevated risk of harm 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.