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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for any or all of the inpatient psychiatric hospitalization services provided by The Menninger Clinic.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. With regard to risk of harm, the records support a score of 3. The patient had a moderate risk of harm as she was unable to care for herself and relied on her parents, who lived in a different city, to meet her needs.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to her inability to function outside of the hospital setting. The patient had withdrawn socially, relied on her parents for assistance, and reported an inability to function. With regard to comorbidity, the records support a score of 4. The patient had major comorbidity due to symptoms of gastroesophageal reflux disease (GERD), costochondritis, lymphocytosis, and low vitamin B12 levels.In terms of level of stress of the recovery environment, the records support a score of 4.  The patient had a seriously stressful environment due to isolating herself to her apartment in Portland, without any social supports outside of her parents in San Francisco. The records noted that the patient had enormous stress from trying to meet the expectations of others and fears of dying. With regard to level of support of the recovery environment, the records support a score of 4 as the patient was isolated socially and physically. She relied on her parents, who lived in a different city, to meet her material and emotional needs. In terms of resiliency and treatment history, the records support a score of 4. The patient had not responded to prior attempts at treatment. With regard to treatment acceptance and engagement, the records support a score of 4. The patient had difficulty engaging in treatment prior to admission and continued to remain guarded, disengaged, and superficial during her hospitalization. Thus, the patient had a total score of 27. The records support a 4 in terms of risk of harm and functional status. In this case, the recommended level of care was medically monitored residence-based services. In this patients case, inpatient psychiatric hospitalization services provided by The Menninger Clinic were not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, inpatient psychiatric hospitalization services provided by The Menninger Clinic were not medically necessary for the treatment of this patient.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.