Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 23-year-old female with no formal psychiatric history. The patient has requested reimbursement for inpatient hospitalization care from 4/13/21 through 4/21/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that 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, the patient met the criteria for inpatient services provided from 4/13/21 through 4/21/21. Dimension 1 (risk of harm) assesses potential for harm to self or others. On presentation to the emergency department, the patient was very disorganized but did endorse suicidality. Additionally, the patient was paranoid, wandering outside the home, vigilant to possible threats and compromising her own safety with lack of awareness of the environment. The records support a score of 4 for this dimension. Dimension 2 (function) assesses the degree to which a person is able to fulfill social responsibilities, interact with, maintain physical functioning and capacity for self-care. In this case, the patient was repeatedly agitated on the inpatient unit, requiring medication. She was unable to tolerate social interactions or groups and neglected activities of daily living. The patient was unable to be managed at home without being monitored around the clock, even on discharge from the unit. Thus, the records support a score of 5 for this dimension. Dimension 3 (comorbidity) assesses potential complications in the course of treatment due to acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder. The patient had iron deficiency anemia and numerous abnormalities rheumatologically and neurologically that needed to be pursued through further testing and neuroimaging, although the patient was too paranoid to cooperate for an MRI. Thus, the records support a score of 4 for this dimension. Dimension 4A (recovery environment a stress) assesses the stressors in the environment, social circumstances, and interpersonal relationships. Prior to her admission, the patient perceived significant overwhelming demands in her job that she was unable to meet, prompting her to quit her job but then decompensating further. Thus, the records support a score of 4 for this dimension. Dimension 4B (recovery environment dimension a support) assesses the presence of family and social support to augment the recovery environment. Although the patientas parents are supportive, the patient was so ill that she was unable to access resources from her parents, and the parents were no longer able to keep her safe outside the hospital. Thus, the records support a score of 4 for this dimension. Dimension 5 (treatment and recovery history) assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. Despite full and adequate trial of Risperdal in the hospital, patient continued to be disorganized and paranoid. She had no prior psychiatric history before this admission. Thus, the records support a score of 5 for this dimension. Dimension 6 (engagement) assesses a patientas understanding of their illness and treatment, and ability and willingness to engage in the treatment process. In this case, the patientas paranoid ideation and persecutory delusions prevented her from engaging in groups and milieu therapy in the hospital. She had great difficulty actively engaging in recovery due to her symptoms and disorganization. Thus, the records support a score of 5 for this dimension. These findings give the patient a composite score of 31, which is consistent with medically managed residence-based services or inpatient level of care. Per LOCUS, the patientas scores of 4 for risk of harm and 5 for functional status also support treatment at Level 6 medically managed residence-based services level of care. For these reasons, the inpatient psychiatric admission was medically necessary. Therefore, inpatient hospitalization care from 4/13/21 through 4/21/21 was medically necessary for the treatment of this patient.