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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient psychiatric 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, this patient did not meet the criteria for the inpatient psychiatric treatment services. For dimension 1, the patient was at serious risk of harm (score 4) due to reports from the patient that his symptoms were worsening and he was having episodic suicidal thoughts without intent and did not want to act on them. The records document current suicidal or homicidal ideation with expressed intentions and/or past history of carrying out such behavior but without means for carrying out the behavior, or with expressed inability or aversion to doing so, or with ability to contract for safety. For dimension 2, the patient demonstrated serious functional impairment (score 4) considering his inability to work at his usual profession during this episode of major depression. There is evidence of inability to perform close to usual standards in school, work, parenting, or other obligations and these responsibilities were completely neglected on a frequent basis or for an extended period of time. For dimension 3, the patient has significant co-morbidity (score 3) given his sequelae of congenital heart disease and previous cardiac surgery. The patient required weekly electrocardiogram monitoring while on medications known to increase the QT interval. The patient also has a history of alcohol use disorder and cannabis use disorder but reported he had been mostly sober from alcohol since rehabilitation. The records document that medical conditions existed, or had a high likelihood of developing, which may have required intensive, although not constant, medical monitoring. For dimension 4A, the patients recovery environment was moderately stressful (score 3). The provider noted that the patient went through a breakup of his engagement and left his job within recent months due to his illness. The patient had significant discord or difficulties in family or other important relationships or alienation from social interactions, and perception that pressure to perform surpassed his ability to meet obligations in a timely or adequate manner. For dimension 4B, the patients recovery environment provided limited support (score 2) due to support from his father, as well as his outpatient psychiatrist and therapist. The patients supportive resources were not abundant but were capable of and willing to provide significant aid in times of need. For dimension 5, the patient demonstrated poor response to treatment and recovery management (score 4). The provider charted that previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. The patient showed an incomplete response to treatment for depression and obsessive compulsive disorder. For dimension 6, the patient exhibited limited engagement and recovery (score 3) due to his limited desire or lack of confidence to change despite intentions to do so. The records document that the patient was engaged with his treatment, and he participated in an array of services. This patients composite score is 23, which is consistent with medically monitored residence-based services. The patients scores of 4 on risk of harm and functional status support medically monitored residence-based services. For these reasons, the inpatient psychiatric treatment services were not medically necessary for 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 with subspecialty certification in addiction medicine 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.