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

Nature of Statutory Criteria/Case Summary: An enrollee diagnosed with bipolar mood disorder and mania with psychotic features. The patient arrived to the emergency department exhibiting erratic and paranoid behavior and was placed on an involuntary hold. The patient was then admitted to a residential treatment center. The patient was noted to be hyperverbal and manic. The patients mood was euphoric, his behavior was manic, and he reported anxiety. He required medications for acute anxiety and agitation, receiving haloperidol and lorazepam throughout the treatment program. The patient was discharged but reported nightmares and being agitated after discharge. The patient was again admitted to a residential treatment center and reported anxiety. The patient was noted to be was manic and hyperverbal. The patient was reported to be restless and pacing. The patient left the residential treatment program against medical advice. At issue in this case is whether residential treatment center services that were provided were medically necessary for the treatment of the patients medical condition. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by behavioral health managers and clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm the patients score is 4, due to the patients erratic behavior and being unable to care for himself. For functional status, the patients score is 4, due to serious decrease in the quality of his interpersonal interactions with his family and loss of his job due to behavioral issues. For comorbidity the patients score is 1, due to no documented evidence of medical illness or current substance use disorder. For recovery environment level of stress, the patients score is 3, due to the patients parents not allowing him to live in their home and loss of his job. For recovery environment level of support, the patients score is 1, due to limited documentation on sources of support. For resiliency and treatment history, the patients score is 3, due to the patient not improving with outpatient treatment, inpatient treatment, or medication. The patients composite LOCUS score is 18. The patient had a serious potential for risk of harm and had a serious impairment in functional status; therefore, the provided residential treatment center services that were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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.