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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for psychiatric inpatient services. Findings: 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. Applying the LOCUS framework, the patient met the criteria for psychiatric inpatient services.For dimension 1, the patient was at serious risk of harm (score 4) due to expression of suicidal ideation for five days prior to admission, recent impulsive behavior, and loss of self-control. The records document harmful behaviors as well as compromise in the patients ability to care for himself or be adequately aware of his environment due to his psychotic symptoms. The patient has a history of clear compromise of ability to care adequately for oneself or to be adequately aware of environment. For dimension 2, the patient demonstrated serious functional impairment (score 4) as he was recently jailed for assaultive behavior in the context of profound manic and psychotic symptoms. Even while hospitalized, the patient continued to be significantly manic and psychotic with a clear inability to function in society. The patient showed a serious decrease in the quality of interpersonal interactions with consistently conflictual or otherwise disrupted relations with others, which included impulsive and aggressive behaviors. For dimension 3, the patient has major comorbidities (score 4) given his history of hyperlipidemia, which can be worsened with psychotropic treatment. Additionally, the patient had a syncopal episode or seizure during his admission, and he has a history of significant substance use, which posed a serious threat to his recovery. Medical conditions exist which are clearly made worse by the existence of the presenting disorder. For dimension 4A, the patients recovery environment was highly stressful (score 4). The records document that the patient was recently incarcerated, and he is otherwise homeless. This supports severe disruption in life circumstances such as going to jail, losing housing, or living in an unfamiliar, unfriendly culture. For dimension 4B, the patient has shown poor response to treatment and recovery management (score 4) considering his recent incarceration and homelessness. The patient is largely estranged from his family, although his mother was an advocate for his treatment. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 5, the patient was unengaged and stuck (score 5) given his inability to adhere to outpatient treatment and requiring repeated psychiatric hospitalizations for significant manic and psychotic symptoms. Past or current response to treatment has been quite minimal, even with intensive medically managed exposure in highly structured settings for extended periods of time. For dimension 6, the patient was unengaged and stuck (score 5). The provider noted that the patient required a court order for treatment and for medication administration. He was disengaged on the unit, not participating in groups and continued to be significantly psychotic impairing his ability to engage or trust others. The patient was unable to actively engage in recovery or treatment and had no current capacity to relate to another or develop trust. These findings give the patient a composite score of 30, which is consistent with medically managed residence-based services. Per LOCUS, the patients scores of 4 for functional status and self-harm also support treatment at Level 6 medically managed residence-based services level of care. For these reasons, the psychiatric inpatient services were medically necessary for treatment of this patient. In terms of level 6, patient meets criteria for level 6B, or medically managed extended care residential programs given his prolonged deterioration and dysfunction and disengagement in treatment as well as not being able to be adequately stabilized within a short period of time requiring many months of treatment. Given these findings, the psychiatric inpatient services were medically necessary for 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.