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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient treatment. 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 treatment.For dimension 1, the patient was at serious risk of harm (score 4) due to a denial of suicidal ideation, but her substance use resulted in loss of self-control. The records document that the patient demonstrated a clear compromise in her ability to care for herself or to be adequately aware of environment. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her presentation as disheveled, easily overwhelmed, unable to make decisions for herself. The patient was unable to perform close to usual standards to be able to function in school or work, and these obligations and these responsibilities may be completely neglected on a frequent basis or for an extended period of time. For dimension 3, the patient has major co-morbidity (score 4) considering her substance use and continued push for benzodiazepines, pain medications, and stimulants. The patients uncontrolled substance use occurred at a level that posed a serious barrier to her recovery from any co-occurring psychiatric disorder. For dimension 4A, the patients recovery environment was highly stressful (score 4). The provider noted that the patient was homeless prior to treatment. The records document that the patient had difficulty avoiding exposure to active users and other pressures to partake in alcohol or drug use. For dimension 4B, the patients recovery environment provided minimal support (score 4) due to the patients homelessness prior to RTC and limited supports. The provider noted that the patients only support was her mother. Very few actual or potential sources of support were available. For dimension 5, the patient exhibited poor response to treatment and recovery management (score 4) given the patients admission to inpatient from RTC after becoming hostile and in an altercation with a staff member at the RTC. The patient continued to have significant symptoms despite intensive treatment and highly structured treatment setting. The records support that previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 6, the patient demonstrated minimal engagement and recovery (score 4) given her great difficulty accepting the reality of her illness and accepting any responsibility for her recovery. The patient did not accept any responsibility for recovery or felt powerless to do so. These findings give the patient a composite score of 28, 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. Moreover, the inpatient psychiatric services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and were not primarily for the convenience of the patient or provider. For these reasons, the inpatient treatment was 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.