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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient behavioral health services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. In cases such as this, an evidence based, objective, instrument such as the Level of Care Utilization System (LOCUS) is an accepted, national standard for determining the appropriate level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible.  The patient met the following criteria: According to the records, it does not appear that the patient has a history of suicide attempts. There was no documentation that the patient had any suicidal ideation. As such, this patients risk of harm is rated as 2 which correlates to low risk of harm. The patients functional status is a 3, moderate impairment. On admission, the patient was severely impaired and required hospitalization. However, the patient improved and was medication compliant. The record indicates that the patient was cooperative. The circumstances along with the patients symptoms, which led to his hospitalization such as disorganization, psychosis, and hallucinations, seemed to have resolved with treatment. The patient continued to have ongoing deficits with his interpersonal relationships and continued to have the inability to fulfill occupational or educational responsibilities.  Medical/addictive/psychiatric co-morbidities is scored a 3, significant co-morbidity. The patient had a co-morbidity of schizophrenia, alcohol use disorder, and methamphetamine use disorder. The patient did not have any serious medical problems. Recovery environment is scored a 3, moderately stressful environment. It appears that the patient is homeless by choice. The patient had lived with the patients mother on several occasions but would leave the home. The patients level of support is scored a 3, limited support in environment. The patients mother is supportive, but the patient has a history of being resistant to parental support.  The patient will partially utilize resources when in extreme need. The patients treatment history is scored a 3, equivocal response to treatment and recovery. The patient has had three to four prior inpatient hospitalizations, and the patient has a tendency to be non-compliant with treatment. The patients methamphetamine and alcohol use worsens his schizophrenia. The patients engagement and recovery status is scored a 3, limited engagement and recovery. The patient was cooperative with staff and compliant with medications. However, the patient has limited ability to accept responsibility for sustained recovery and does not use available resources independently unless the patient is in extreme need. Based on the LOCUS criteria, the patients total score is 20. According to this criteria, the patient would meet criteria for partial hospitalization program and not inpatient behavioral health services. The patient continues to require treatment for his schizophrenia, alcohol use disorder, and methamphetamine use disorder, but the patient could have continued treatment in a less restrictive environment. Therefore, inpatient behavioral health services were not and are not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not and are 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.