Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services and prospective authorization and coverage for future PHP services for a period of four weeks. 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 had a serious risk of harm, due to a history of suicidal ideation and behavior (SIB), and audio and visual hallucinations.  In terms of functional status, the records support a score of 2. The documentation noted mild functional impairment as the patient was unemployed due to her symptoms, but was able to live independently. With regard to comorbidity, the records support a score of 2. The records documented the presence of anorexia and food restricting. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a mildly stressful environment as she had a good relationship with her mother, but her paranoia can interfere with her family relationships.With regard to level of support of the recovery environment, the records support a score of 2 as the patient had a supportive recovery environment.In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment, reporting over a hundred inpatient psychiatric hospitalizations, multiple treatment attempts in outpatient care, intensive outpatient programs (IOP), and PHP, and multiple medication changes, with limited benefit. With regard to treatment acceptance and engagement, the records support a score of 2. The patient had been adherent with treatment and was cooperative.In terms of engagement and recovery status, the records support a score of 3. The patient had few trusting relationships due to her paranoia, did not use available resources independently, and required structure and support.Thus, the patient had a total score of 22. The risk of harm score is 4, which mandates a level 5 service (residential). In this case, the request was for PHP services, which is supported by both the total score of 22, and the risk of harm score of 4.  Therefore, PHP services were medically necessary for the treatment of this patient. As the patients symptoms have improved, a transition to IOP level of care may be appropriate at this time. Therefore, the requested future PHP services for a period of four weeks are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.