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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient behavioral health care 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 met the criteria for inpatient behavioral health care services. For dimension 1, the patient was at extreme risk of harm (score 5) due to compromise of his ability to care for himself or adequately monitor his environment. He demonstrated evidence of deterioration in his physical condition related to these deficits. The patients nutrition status was compromised with low potassium and confusion upon admission. He lacked decision-making capacity due to severe and gravely disabled condition. The records document extreme compromise of ability to care for oneself or adequately monitor environment with evidence of deterioration in physical condition or injury related to these deficits. For dimension 2, the patient demonstrated severe functional impairment (score 5) given his extreme deterioration in social interactions which included chaotic communication, threatening behaviors with little or no provocation, or minimal control of impulsive, aggressive or otherwise abusive behavior. His neglect of personal hygiene and appearance and inability to attend to basic needs such as food intake resulted in serious harm to his health. The patients intake gradually improved during his admission with the assistance of nutritional counseling. The provider reported that the patients ability to complete activities of daily living was poor. The records describe the patient as very isolative and withdrawn. The patients psychosis impaired his ability to provide a viable plan of self-care. For dimension 3, the patient has severe comorbidities (score 5) considering his severe acute psychosis. Severe psychiatric symptoms were present, which seriously impaired his ability to function and prevent recovery. The patient was disorganized and psychotic, which impaired his ability to provide a viable plan for self-care. For dimension 4A, the patients recovery environment was extremely stressful (score 5). The patient had significant cognitive symptoms related to his schizophrenia and he was unable to care for himself. He was living with his mother, who also has health issues, prior to admission and he was not compliant with his medications. The patient has the sustained inability to meet basic needs for physical and material well-being. For dimension 4B, the patients recovery environment was not supportive (score 5). The treatment team was informed that the patient could not return home since he was unable to function independently. His providers sought out a structured environment as a step down, once the patient was stable. By discharge, he was No sources for assistance were available in environment either emotionally or materially. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4). Attempts to maintain whatever gains attained in less restrictive settings have had limited success, even for limited time periods or in structured settings. The patient was noncompliant with medication and demonstrated grave disability. For dimension 6, the patient was minimally engaged in recovery (score 4). He rarely, if ever was able to accept reality of his illness or any disability that accompanies it, but may acknowledge some difficulties in living. This gives the patient a composite score of 33, which is consistent with medically managed residence-based services. Given this support, the inpatient behavioral health care 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.