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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for psychiatric inpatient hospital 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. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to being admitted for hospitalization after cutting himself deeply, with recent escalation in cutting and a lack of ability to do anything else to cope with current stressors. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient had become more withdrawn, with an increase in impulsive and reckless behaviors including cutting. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity due to a history of learning disorder and a diagnosis of TBI in the last three years, causing him to fall behind in school, increasing his anxiety about being able to graduate, and making it more difficult for him to engage in DBT homework. The patient had deep cuts, which were monitored while in the hospital.  In terms of level of stress of the recovery environment, the records support a score of 4.  The patient had a highly stressful environment as he lived alone in a rented room and reported feeling overwhelmed with demands to meet obligations, leading him to cut himself to punish himself for not managing the stress and demands. With regard to level of support of the recovery environment, the records support a score of 3 as the while the patients parents and girlfriend were actively involved, the patient isolated and had limited ability to utilize resources when feeling overwhelmed. In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible response to treatment, as psychiatric hospitalization the prior year for suicidal ideation and outpatient treatment had failed to achieve remission of symptoms and had a questionable impact on his presenting symptoms. With regard to treatment acceptance and engagement, the records support a score of 4. The patient had varying engagement in treatment with limited ability to accept responsibility for his recovery, avoiding social contact and having trouble using treatment resources if left to his own devices. Thus, the patient has a total score of 28. The records supported a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care was medically managed residence-based services or inpatient psychiatric hospitalization. With the functional impairment and elevated risk of harm noted, the patient met LOCUS 6 criteria. Therefore, reimbursement for psychiatric inpatient hospital services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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.