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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient psychiatric treatment program services. Findings:  The physician reviewer found that American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adolescents 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.The records provided for review do not support the medical necessity of the inpatient psychiatric treatment program services. The patient has been at low risk of harm (score 2) due to a lack of current suicidal ideation but a history of past about behaviors. The progress notes report the patient has not exhibited any anger outbursts, aggression, or self-harm. The patient has demonstrated moderate functional impairment (score 3) due to overall good daily function while on the inpatient unit, with a history of past problems with hygiene and appearance. The progress notes indicate the patient continues to have some signs of psychosis. However, the progress notes indicate he is at his baseline level of psychosis that includes auditory hallucinations. The progress notes do not indicate that the patient reported that his auditory hallucinations were troubling or that the hallucinations improved to any significant degree. The patient presents with minor co-morbidity (score 2) without a recent history of substance use and medical problems that are under control. The patients recovery environment is moderately stressful (score 3) due to some issues with independent living skills. The patient it appears content with his possible discharge placement options. The patients recovery environment is supportive (score 2) and includes a residential living environment step down unit with the support of behavioral health providers. The patient has demonstrated some positive response to treatment (score 3) but continues to report residual auditory hallucinations that appear to be at his baseline. The patient has been positive and engaged in his treatment program (score 2). The progress notes indicate the patient has been calm, cooperative, and open to discussion of his symptoms. Psychiatric progress notes indicate the patient has been adherent with his prescribed medications. Further, the patient has discussed insight into his need for treatment. This gives the patients stay a composite score of 17, which correlates with high intensity community based services. According to the patients score on the LOCUS, inpatient psychiatric treatment program services were not and are not medically necessary for 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.