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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient mental health 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 criteria, the patient did not and does not meet the criteria for psychiatric inpatient services provided and forward. For dimension 1, the patient has been at moderate risk of harm (score 3) due to her long history of suicidal ideation but no history of actual attempts, and no intent at the time of admission. Her risk of harm does not represent a significant elevation from her usual state. History of chronic impulsive/suicidal behavior or threats, but current expressions did not represent significant change from usual behavior. For dimension 2, the patient has demonstrated serious functional impairment (score 4) given her significant deficits in her ability to fulfill obligations and engage in socially constructive activities. These deficits have been ongoing. However, it does appear that there has been recent deterioration from her baseline functioning, with deterioration in self-care, withdrawal, and physical functioning. Serious decrease in the quality of interpersonal interactions with consistently conflictual or otherwise disrupted relations with others, which may include impulsive, aggressor or abusive behaviors. Serious disturbances in physical functioning such as weight change, disrupted sleep, or fatigue that threaten physical well-being. For dimension 3, the patient has significant comorbidities (score 3) considering her several physical problems which cause her pain and may have an adverse effect on her psychiatric condition. Medical conditions exist which may adversely affect the course of the presenting disorder. For dimension 4A, the patients recovery environment has been highly stressful (score 4). The records document significant stressors related to her marriage, home environment, and ability to cope with change. Serious disruption of family milieu which may be due to illness, death, divorce or separation of parent and child, severe conflict, torment, and/or physical abuse. For dimension 4B, the patients recovery environment has provided minimal support (score 4) since she does not have any significant friendships that may be supportive. Her parents may be supportive, but they live far away. She has minimal professional supports. Usual sources of support may be somewhat ambivalent, alienated, difficult to access, or have a limited amount of resources they are willing or able to offer when needed. For dimension 5, the patient has exhibited negligible response to treatment (score 5) as the provider reported that she has undergone extensive treatment in the past with minimal improvement in symptoms. Symptoms have been persistent and functional ability shows no significant improvement despite this treatment exposure. For dimension 6, the patient has shown limited engagement and recovery (score 3) considering her ability to engage in treatment and demonstrate an understanding and acceptance of her illness, but she lacks the confidence to make needed changes. She has limited ability to take responsibility for her recovery. Has limited desire or lacks confidence to change despite intentions to do so. The patient has limited ability to accept responsibility for recovery. These findings give the patient a composite score of 26, which is consistent with Level 5 medically monitored residence-based services, which was reportedly offered to the patient and declined. All told, psychiatric inpatient services, and future psychiatric inpatient services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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.