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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient behavioral health services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. To objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria is used. This is an accepted, national standard for determining the appropriate level of care for adults.  The patient met the following criteria: Her risk of harm is scored a 2 which corresponds to low risk of harm.  The patient has no documentation of a prior suicide attempt. The patient did not have any suicidal ideation. Prior to this episode, the patient had no prior psychiatric history. Her functional status is rated as a 3, moderate impairment. Per documentation, the patient had normal functioning prior to this acute psychotic episode. She then had significant disturbances in her sleeping and eating habits and was not eating or sleeping for two days prior to being admitted to the inpatient psychiatric hospital. However, the patient was sleeping eight hours at night and eating 30 to 90% of her meals. The patient continued to have paranoid delusions. Her medical, addictive, and psychiatric co-morbidity is scored a 2, minor co-morbidity. The patient had no prior psychiatric history prior to this acute psychotic episode. The patient did not have substance abuse problems. Her recovery environment is a 2, mildly stressful environment. The patient has a supportive husband. Her level of support is a 2, which correlates to a supportive environment. The patients husband is supportive. Her treatment history is a 1, fully responsive to treatment and recovery. The patient has had no prior treatments as she never had a prior psychiatric history. Her engagement and recovery status is a 3, limited engagement and recovery. The patient is mostly cooperative with staff. She was compliant with medications. However, she is uncertain in her acceptance or understanding of her illness. She will refuse certain medical interventions due to paranoid delusions such as refusing a computed tomography scan due to her feelings of being kidnapped. According to the LOCUS criteria, this patients composite score is 15. Based on these criteria, this patient would meet criteria at a lower level of care such as at an outpatient treatment. This patient continued to require treatment for unspecified psychosis, but this could have been done in a less restrictive environment. Therefore, inpatient behavioral health services were not medically necessary for treatment of this patients medical condition. 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.