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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient mental health 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. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm. He was admitted for treatment after he threw things and endorsed homicidal ideation towards his mother in the context of relationship conflict and command auditory hallucinations. The records documented recent excessive substance use, likely contributing to loss of self-control and harmful behaviors, prior to admission.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to the patients issues with interpersonal interactions prior to admission and throughout the hospitalization, documenting consistently conflictual relations with his mother, and impulsive and aggressive behaviors.With regard to comorbidity, the records support a score of 4. The patient had major comorbidity due to the presence of uncontrolled substance use leading up to his admission that posed a serious barrier to recovery. The patient had sleep apnea with ongoing symptoms, which may have contributed to mood issues, and a diagnosis of autism spectrum disorder that may have contributed to interpersonal difficulties. In terms of level of stress of the recovery environment, the records support a score of 4.  The patient had a highly stressful environment due to significant conflict with his mother. With regard to level of support of the recovery environment, the records support a score of 4 as the patient was isolated socially due to his social anxiety and interpersonal difficulties. He relied heavily on his mother, with whom he lived, but also had a very conflictual relationship with her. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as he had previously been hospitalized psychiatrically numerous times with failure to achieve remission of symptoms. With regard to treatment acceptance and engagement, the records support a score of 4. The patient had varying engagement in treatment with limited ability to accept responsibility for his recovery, as he avoided social contact and had trouble using treatment resources if left to his own devices. Thus, the patient has a total score of 28. The records support a 4 in terms of functional status and risk of harm. In this case, the recommended level of care is medically managed residence-based services or inpatient psychiatric hospitalization. With the functional impairment and elevated risk of harm noted, the patient met LOCUS Level 6 criteria. In this patients case, inpatient mental health treatment services were in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, inpatient mental health treatment services were medically necessary for the 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.