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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient psychiatric hospitalization. The progress notes for the period of inpatient psychiatric hospitalization reflect that the patient was no longer stating suicidal or homicidal ideation or intent during this period. He was no longer reporting any auditory hallucinations and his paranoia was improved. It was noted that the patient did not attend some groups despite encouragement or altering the group to the patients liking. With respect to the groups he did attend, however, he was cooperative, calm and appropriate. The patients mental status exam showed him to be disheveled but cooperative, and he behaved with good eye contact. During the period of inpatient psychiatric hospitalization, the patient was not reported to have any hallucinations, delusions, phobias, obsessions or compulsions, and he did not have any suicidal or homicidal ideation.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 and recovery status. The composite score is then used to determine the level of care needed.Regarding the six LOCUS dimensions, the patient had a low to minimal risk of harm (a score of 1-2) due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 3 due to his hygiene and appearance. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 1 for no comorbidity. In terms of the level of stress of the recovery environment, the records support a score of 1 due to a low stress environment. With regards to the level of support for the recovery environment, the records support a score of 1 due to family support and the availability of treatment resources with his parents being conservators. With regards to treatment and recovery history, the records support a score of 2, as the patient had previous treatment and was familiar with the experience of treatment. In terms of engagement and recovery status, the records support a score of 3 due to some variability in hesitation. Thus, the patient had a composite score of 12-13. This correlates with treatment in a community-based outpatient clinic setting.The submitted documentation fails to demonstrate the medical necessity of inpatient psychiatric hospitalization during the period of inpatient psychiatric hospitalization at issue. During this period, the patient was not reported to have any hallucinations, delusions, phobias, obsessions or compulsions, and he did not have any suicidal or homicidal ideation. Furthermore, analysis using the LOCUS framework for determining the appropriate level of care for adults needing mental health treatment concluded that the patient had a composite score of 12-13, which correlates with treatment in a community-based outpatient clinic setting. Accordingly, inpatient psychiatric hospitalization during the period at issue was not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue 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.