Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the inpatient behavioral health level of care services at Oceanview Psychiatric Health Facility.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 3. The records did not indicate a history of or current suicidal or homicidal ideation but noted that the patient was distressed and somewhat agitated. In terms of functional status, the records support a score of 3. The documentation noted significant functional impairment due to ongoing deficits in his ability to engage in socially constructive activities.With regard to comorbidity, the records support a score of 3. The patient presented with psychiatric disturbances, likely related to his substance use. The records noted an impulsive and angry outburst had resulted in this hospital admission. The patients access to substances was cut off while in treatment, and it did not appear that he had been using substances for at least two weeks prior to admission.  In terms of level of stress of the recovery environment, the records support a score of 2.  The patient did not appear to have significant stressors as he was supported by his mother, not employed, and without significant changes in his living situation or relationships. His major source of stress was likely related to the potential exposure to substances outside of a protected setting. With regard to level of support of the recovery environment, the records support a score of 2 as the patients mother was supportive and involved. In terms of resiliency and treatment history, the records support a score of 4. The patients substance use, instability and irritability have continued despite past treatments and interventions, even in intensive forms. With regard to treatment acceptance an engagement, the records support a score of 3. While the patient had limited insight into his conditions, he demonstrated some intention to engage in treatment. Thus, the patient had a total score of 20. In this case, the recommended level of care was medically monitored non-residential services. Therefore, inpatient behavioral health level of care services at Oceanview Psychiatric Health Facility were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.