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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for acute inpatient psychiatric services at Stanford Medical Center. 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 5. The patient had extreme risk of harm, due to continued suicidal ideation throughout her psychiatric admission. The records noted that the patient attempted suicide by strangulation while on the inpatient unit, requiring transfer to a locked unit for her safety. The patient has repeatedly reported throughout her admission that she had decided to kill herself and appeared to be adamant in this decision, making various attempts even in highly structured, protective settings.In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment. The patient was not working and on temporary disability since November 2020. The records noted poor grooming and hygiene, and withdrawal and isolation from others in the unit. With regard to comorbidity, the records support a score of 2. The patient had minor comorbidity due to the presence of a UTI on admission and cystitis.In terms of level of stress of the recovery environment, the records support a score of 4.  The patient had a highly stressful environment without any social support. The records noted that the patients family was in Germany, and that her brother had committed suicide. With regard to level of support of the recovery environment, the records support a score of 4 as the patients only social support was her roommate, who was unable to provide sufficient resources for patient, and had a conflictual and distanced relationship with her family. In terms of resiliency and treatment history, the records support a score of 5. The patient had negligible response to treatment, due to negligible improvement in her mood and suicidality despite prior psychiatric hospitalization and admission to a RTC prior to the psychiatric admission at issue. With regard to treatment acceptance and engagement, the records support a score of 4. The records noted that the patient was irritable with treatment team and was minimally engaged with group discussions. Thus, the patient has a total score of 28. The records support a 5 in terms of risk of harm and a 4 in terms of functional status. In this case, the recommended level of care was medically managed residence-based services or inpatient psychiatric hospitalization. With the functional impairment and elevated risk of harm noted, the patient meets LOCUS Level 6 criteria. In this patients case, acute inpatient psychiatric 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, acute inpatient psychiatric services at Stanford Medical Center 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.