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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for adult inpatient mental health specialty care 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, this patient did not meet the criteria for inpatient mental health specialty care services. For dimension 1, the patient was at significant risk of harm (score 3) given his history of command auditory hallucinations and suicidal ideation that has required at least two inpatient psychiatric hospitalizations in the past. During this inpatient admission, he did not report suicidal ideation or command auditory hallucinations. No active suicidal or homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior. For dimension 2, the patient demonstrated serious functional impairment (score 4) due to his inability to continue in school, hold a job, or interact with others in healthy and consistent ways due to his illnesses. He was able to interact with staff, family over the phone, and follow directions in a structured setting during this admission. There was significant withdrawal and avoidance of almost all social interaction.For dimension 3, the patient has major comorbidities (score 4) including schizoaffective disorder, bipolar type, alcohol use disorder, and cannabis use disorder. The patient did not have medical or developmental issues during the period under review. Psychiatric symptoms were present that clearly impaired functioning, persisted in the absence of stressors, and seriously impair recovery from the presenting condition. For dimension 4A, the patients recovery environment was highly stressful (score 4) due to his troubled relationship with his parents in understanding their concerns and he was only open to superficial interactions in groups and individual therapy. This supports inability to meet needs for physical and/or material well-being. For dimension 4B, the patients recovery environment provided limited support (score 3). The records document that the patients family participated in family therapy and phone calls with the patient. No other supports were identified. The patients family demonstrated only partial ability to make necessary changes during treatment. For dimension 5, the patient exhibited moderate or equivocal resiliency and response to treatment (score 3). The provider noted that the patient was compliant with medications and he did not report active psychotic symptoms. He was depressed and did not understand his need for treatment. He was previously treated in the inpatient, partial hospital program, and outpatient settings. Previous experience in treatment at low level of intensity has not been successful in relief of symptoms or optimal control of symptoms.For dimension 6, the patient was incompletely engaged in treatment (score 3) due to his inability to use treatment to address areas of difficulty. The patient went to groups, individual therapy, and took his medications, but he was limited in his ability to engage in groups and individual therapy. The patient accepted no age-appropriate responsibility role in development, perpetuation, or consequences of the problem. These findings give the patient a composite score of 24, which is consistent with medically monitored residence based services. Therefore, the adult inpatient mental health specialty care services rendered were not medically necessary for 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.