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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in order to objectively determine if the patient meets criteria for length of stay, the records were analyzed based on the Level of Care Utilization System (LOCUS) criteria. This is an accepted, national standard for determining the appropriate level of care for adults. In terms of risk of harm, the records support a score of 4.  The patient has a history of suicide attempt. She has chronic suicidal ideation and can be impulsive. It was noted that the patients suicidal ideation had improved, although her suicidal thoughts remained present.  With regards to functional status, the records support a score of 4.  The patient isolated from staff and the milieu. She did not participate in groups. She had a consistent failure to maintain her personal hygiene and appearance. She is unable to work due to her mental illness. With regards to medical/addictive/psychiatric comorbidity, the records support a score of 3. The patient has a significant comorbidity of schizoaffective disorder, posttraumatic stress disorder, and borderline personality disorder. She also has migraines and has a history of substance abuse. In terms of recovery environment, the records supports a score of 3.  The patient has a moderately stressful environment. The patient just broke up with her boyfriend. She also reported having a conflictual relationship with her mother.  With regards to level of support, the records support a score of 4.  The patient has very limited sources of support. In terms of treatment history, the records support a score of 3. The documentation noted equivocal response to treatment and recovery. The ECT series received inpatient was equivocal and did not achieve complete remission of symptoms. With regards to engagement and recovery status, the records support a score of 4. The patient is minimally involved in her treatment. She relates poorly to treatment providers and isolates from staff.  Therefore, the records support a total score of 25. Thus, the patient would meet criteria for a residential treatment program. Per the submitted documentation, the patient is able to be treated in a less restrictive environment in a residential treatment center setting. Therefore, acute inpatient psychiatric treatment was not and is not medically necessary for the treatment of this patient. 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.