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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient psychiatric treatment services. 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 inpatient psychiatric services.For dimension 1, the patient was at extreme risk of harm (score 5) since he presented with suicidal ideation daily for the prior two weeks, worsened over the last three years, with plan to shoot himself or hang himself with means to carry out his plans. The patient endorsed feeling hopeless and he was unable to contract for his safety. The patients risk for suicidality was increased following initiation of treatment with citalopram. Current suicidal behavior or such intentions with a plan and available means to carry out this behavior without expressed ambivalence or significant barriers to doing so. For dimension 2, the patient has demonstrated severe functional impairment (score 5) due to his inability to work and complete social isolation at the time of admission. The provider noted that while on the inpatient unit, the patient was guarded, and his affect was flat. The patient continued to withdraw from people around him. Development of complete withdrawal from all social interactions. For dimension 3, the patient has minor comorbidities (score 2) given his history of cannabis use with occasional episodes of misuse. The records suggest that the episodes were self-limited and did not adversely affect the course of his psychiatric illness. Occasional episodes of substance misuse, but any recent episodes are self-limited, show no pattern of escalation, and there is no indication that they adversely affect the course of a co-occurring psychiatric disorder. For dimension 4A, the patients recovery environment was highly stressful (score 4). The provider noted that the patient was overwhelmed with stress from work and school. Overwhelming demands to meet immediate obligations were perceived. For dimension 4B, the patients recovery environment provided minimal support (score 4). The patient lives with his grandparents and has struggled since the death of his mother in 2013. The patient has withdrawn from all social supports, and patients grandparents are unable to meet patients emotional needs. 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). Outpatient care failed to achieve optimal control of his symptoms. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For dimension 6, the patient demonstrated minimal engagement and recovery (score 4). Based on ambivalent attachment to his outpatient provider on admission and discharge planning, the patient did not engage with outpatient care sufficiently to meet his needs outside of the structured environment of the inpatient unit. Avoided contact with and use of treatment resources if left to own devices. These findings give the patient a composite score of 28, which is consistent with Level 6 medically managed residence-based services. Per LOCUS, the patients scores of 5 for risk of harm and functional status also support treatment at Level 6 medically managed residence-based services. Therefore, inpatient psychiatric treatment 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.