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. 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) due to a lack of current suicidal ideation, but the patient previously required hospitalization for suicidal ideation in the past year. The patient also has a history of cutting with ambivalence about dying over the last few years. The records document 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 his inability to work or start school due to his symptoms. Even while in RTC, the patient has not been eating, has disrupted sleep, and is having trouble functioning, presenting at times as agitated and in distress. The patient has shown serious disturbances in physical functioning such as disrupted sleep that threaten physical well-being. For dimension 3, the patient has significant comorbidity (score 3) considering his recent substance use which has had clearly detrimental effects on his psychiatric symptoms but is currently arrested through use of medication and structured setting for treatment. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The records document that the patient has easy exposure and access to substances. Additionally, the patient is living with grandparents and is unable to return home due to his substance use. The patient reports feeling overwhelming demands to meet obligations. The patients girlfriend overdosed in the last few months, and patient revived her, causing him significant ongoing stress. For dimension 4B, the patients recovery environment provides limited support (score 3) since he has a few supportive resources. The patient also has conflictual relationships with his parents and grandmother. There is report that a few supportive resources exist in current environment and may be capable of providing some help if needed. For dimension 5, the patient has shown poor resiliency and response to treatment (score 4) since previous or current treatment has not achieved complete remission of symptoms. The patient has completed detoxification, RTC, and was hospitalized psychiatrically in the past year without complete remission of symptoms. For dimension 6, the patient has exhibited limited engagement and recovery (score 3). The records document that the patient has some variability and hesitation in accepting or understanding his illness. The patient has refused treatment to be planned after RTC, which indicates a lack of engagement. These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services. Additionally, the patients score of 4 in level of functioning supports placement in RTC. In terms of length of stay, the patient meets criteria for level 5B moderate intensity intermediate stay residential treatment program for up to 60 days due to his ongoing difficulties with life circumstances exceeding his ability to cope and serious impairment in expected role functioning at home, work, or school. 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. Therefore, 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. 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.