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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for inpatient mental health care services. The Health Plan has denied this request indicating that the requested treatment was not medically necessary for treatment of the enrollees behavioral health condition.At issue in this case is whether authorization and coverage for inpatient mental health care services were medically necessary for treatment of the enrollees behavioral health condition.In cases such as this an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining the necessary level of care for adults. In terms of risk of harm, the records support a score of 1-2 due to a lack of current suicidal ideation and no current suicidal or homicidal ideation, plan, intention or severe distress. With regards to functional status, the records support a score of 1-2 due to some problems with group attendance. However for the groups they did attend the patient was found to be supportive. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 considered minor comorbidity based on the information from group attendance where the patient is supportive and asking for help. In terms of level of stress of the recovery environment, the records support a score of 1 due to a low stress environment. With regards to level of support for the recovery environment, the records support a score of 1 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 with previous treatment and the experience of treatment. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into the patient's need for treatment along with insight into their  treatment needs. Thus, the patient has a composite score of 10-12. This correlates with treatment in a community-based outpatient clinic setting. The literature indicates that outpatient treatment with modalities would be clinically indicated for the treatment of this patient. Based on a review of the records provided for the dates in question, the progress note showed this patient appeared alert and oriented in three spheres. The patient was found to be unkempt, withdrawn and avoiding eye contact whereas the patient was denying any auditory or visual hallucinations or delusions. The patient did not have any suicidal or homicidal thoughts or ideation and did not have any active plan. The patient was able to sleep through the night as assessed by the nurse on night shift. Based on the information from the criteria above, the inpatient mental health services were not medically necessary for the treatment of the patients condition. The patient was not a danger to self or others, did not have auditory or visual hallucinations and did not have any delusions, difficulty with sleep or abnormal behavior, which were the conditions that brought the patient into the facility on admission. Clearly the patient was improved based on the documentation provided. Therefore, the requested services were not medically necessary.Final Result: The reviewer determined that the requested services 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.