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 (Level 6) services. Findings:  The physician reviewer found that 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, this patient met the criteria for inpatient mental health (Level 6) services. For dimension 1, the patient was at extreme risk of harm (score 5) due to current suicidal or homicidal behavior without expressed ambivalence or significant barriers to doing so. As of 3/9/21, the patient was still engaged in hitting herself repeatedly. The patient reported that she was likely to harm herself if not in confined setting. For dimension 2, the patient demonstrated serious functional impairment (score 4), given her inability to perform close to usual standards in work, parenting, or other obligations and these responsibilities may be completely neglected on a frequent basis or for an extended period of time. This patient left her abusive husband and has not had a relationship with her six children since she left. She has relied on her niece as her caretaker for the past six months. Hospital notes indicate she was extremely labile, tearful, and hitting herself. The patient also met the subsection for significant withdrawal and avoidance of almost all social interactions. For dimension 3, the patient has significant comorbidities (score 3) considering her diagnoses of cannabis use disorder. The patient reported smoking five joints daily for the past four years, with the last use on the date of admission. This supports recent substance use which has had clearly detrimental effects on the presenting disorder, but which has been temporarily arrested through the use of a highly structured or protected setting. For dimension 4A, the patients recovery environment was extremely stressful (score 5). The records document an acutely traumatic level of stress or enduring and highly disturbing circumstances disrupting ability to cope with even minimal demands in social spheres such as ongoing injurious and abusive behaviors from family member or significant other. The patient separated from her abusive husband six months ago and is going through a divorce. She reports her husband has been physically and emotionally abusive and has turned her six children against her. She reports that he is still contacting her and that he is emotionally abusive despite her living with her niece. For dimension 4B, the patients recovery environment has provided minimal support (score 4) due to her lack of an outpatient psychiatrist or therapist in the community. The patient is in process of divorcing an abusive spouse and she is estranged from her six children. Her only support in the community has been her niece. Existing supports are unable to provide sufficient resources to meet material or emotional needs. For dimension 5, the patient has shown poor response to treatment and recovery management (score 4). The records document that she was psychiatrically hospitalized in December 2020 and she did not receive any follow-up or have any improvement in level of functioning. She spent much of this hospitalization on a 1:1 status for self-injurious behaviors and continued to report inability to cope and suicidal ideation until four days prior to discharge. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure. For dimension 6, the patient has exhibited limited engagement and recovery (score 3) since she  relates to treatment with some difficulty and establishes few, if any trusting relationships, and does not use available resources independently or uses them only in cases of extreme need. These findings give the patient a composite score of 28, which is consistent with Level 6 medically managed residence-based services. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the inpatient mental health (Level 6) services were medically necessary for 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.