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

Nature of Statutory Criteria/Case Summary: female enrollee has requested reimbursement and prospective authorization and coverage for inpatient mental health and inpatient electroconvulsive therapy (ECT) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is three (3), moderate risk of harm. The patient has a history of overdosing in the past. She has chronic impulsive suicidal behavior and suicidal ideation.  The patient still had intermittent chronic suicidal ideation but with no plan. Further hospitalization would not alleviate her chronic suicidal ideation. The patients functional status score is three (3), moderate impairment.  The patient is unable to work due to her impairments and is currently unemployed. She has ongoing severe deficits in interpersonal relationship and her ability to engage in socially constructive activities and maintain responsibilities. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of schizoaffective disorder, borderline personality disorder, PTSD, and prior substance use. The patient also has chronic migraine headaches. The patients recovery environment score is four (4), highly stressful environment. The patient has had significant discord with her ex-boyfriend and her parent. The patient reports that her parent is overly critical of her. It appears that the patient is struggling to meet her physical needs. The patient was attempting to cancel her lease at her apartment and find new living arrangements. The patients level of support score is three (3), limited support. The patient has limited support at this time. Her support revolves around professional resources. The patients treatment history score is three (3), equivocal response to treatment and recovery. Previous ECT treatment had achieved only partial remission of symptoms. The patient had an equivocal response to treatment in this hospitalization. However, the patient did have an intermittent improvement in mood.  The patient had improved enough to not have active suicidal ideation, but continued to have chronic suicidal ideation. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is cooperative and compliant with treatment. Based on these criteria, the patient has a total score of 21, which would meet criteria for a partial hospitalization program. Continued treatment is clinically indicated for the patients borderline personality disorder, schizoaffective disorder, and PTSD. However, the patient has improved enough to be treated in a less restrictive environment. For the reasons provided, the inpatient mental health and inpatient ECT services provided were not and are not medically necessary for treatment of the patients medical 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.