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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for inpatient psychiatric services. The enrollee has a history of major depression, severe; with anxiety, panic disorder, and agoraphobia. She entered the inpatient psychiatric setting. Upon admission, she was tearful, anxious, perseverative, and hyper-focused on medications. She reported a decrease in eating and sleeping. She reported feeling isolated and withdrawn and she did not feel safe from hurting herself. She had severe anxiety and could not leave the apartment for fear she may die if she left. During her hospital stay, she was functional in the open unit after being treated in the locked unit. The provider notes at discharge state there is no clinical indication for her to remain in the facility. He notes she is not suicidal; she is agoraphobic. The enrollee was discharged to an intensive outpatient program. The enrollee was not actively suicidal or homicidal. She denied a history of getting angry. She denied psychotic symptoms. She was continued on Paxil. During her inpatient stay, her medication regimen was modified to Paxil, Viibryd  and Ambien. 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 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 enrollees score is 2, due to no current suicidal or homicidal ideation, plan, intentions or severe distress, but there may have been transient or passive thoughts recently or in the past. For functional status, the enrollees score is 4, due to an inability to perform close to usual standards in school, work, parenting or other obligations and these responsibilities may be completely neglected on a frequent basis or for an extended period of time. For comorbidity, the enrollees score is 2, due to the existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. For recovery environment level of stress, the enrollees score is 4, due to an inability to meet the needs for material well-being. For recovery environment level of support, the enrollees score is 3, due to usual sources of support may be somewhat ambivalent, alienated, and difficult to access, or have a limited amount of resources they are willing or able to offer when needed. For treatment and recovery history, the enrollees score is 3, due to previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 2, because she shows some recognition of her personal role in recovery, accepts some responsibility for it, and demonstrates a willingness to change. Although the total score of 20 correlates with Level 4, having a score of 4 on Dimension II correlates with Level 5 care, which refers to residential treatment provided in a community setting.  This level of care has traditionally been provided in non-hospital, free-standing residential facilities based in the community. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.