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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospitalization services provided for treatment of her behavioral health condition. Findings:  The physician reviewer found that to objectively determine if the patient meets criteria for length of stay, the level of care utilization system (LOCUS) criteria. The LOCUS system is an accepted, national standard for determining the appropriate level of care for adults. The patients criteria for admission is the following: The patient has a history of chronic suicidal ideation for the last four to five years. These suicidal behaviors were impulsive. As such, her risk of harm is scored a 3, which is moderate risk of harm. The patients functional status is also scored a 3, moderately impaired. The patient has had conflictual relationship with her peers. She has been unable to work for the last six years due to medical and emotional problems. However, recent gains and stabilizations have been achieved while participating in a structured setting. The patients appearance and hygiene fell below usual standards on a frequent basis. The patient has had no aggression toward others. She was attending group sessions and participating in treatment. With regard to her medical/addictive/psychiatric comorbidities, the patients score is also a 3 which represents significant comorbidities. The patient also uses cannabis and benzodiazepines. The patients medical conditions were stable, and her conditions did not require 24 hour medical monitoring. Her medical conditions may have adversely affected the patients presenting symptoms.  With regard to her recovery environment, this patients score is a 2, which notes a mildly stressful environment.  She has chronic interpersonal difficulties with peers and is very sensitive to perceptions of rejection or abandonment.  As for her supportive environment, her score is a 3, limited supportive environment. The patients mother is supportive of the patient. However, the patients mother does not feel capable of handling the patients chronic suicidal ideation and emotional liability, but the  mother is capable of providing some help if needed. The patients treatment history is scored a 3 noting a moderate/equivocal response to treatment. The patient has had limited prior treatment. She has had no prior inpatient psychiatric hospitalizations. The patient has had partial recovery, which has been maintained in the hospital with strong professional support and in structured settings. Her engagement and recovery status is scored a 3, which is identified as limited recovery engagement.  From the documentation, the patient appears to want to engage in treatment and desires recovery. She was noted as attending groups and taking her medications. However, the patient will also split staff, argue with treatment recommendations and procedures, and debate about her perceived level of care needs. This patients total composite score is 20.  According to the LOCUS criteria, this patient could have been treated in a less restrictive environment.  Therefore, inpatient hospitalization services were not medically necessary for treatment of this patients medical condition.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.