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

 Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient psychiatric care. 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. For dimension 1, the patient was at serious risk of harm (score 4) given her chronic suicidal ideation, history of two suicide attempts, and clear compromise of her ability to care adequately for herself. She was unable to manage herself in a safe manner, as evidenced by pacing the halls at night and non-adherence with medical interventions. The providers noted concern regarding the veracity of the patients repeated denial of suicidal ideation while on the unit. For dimension 2, the patient exhibited severe functional impairment (score 4). On admission, the patient demonstrated severe impairment, which improved to serious impairment at the time of discharge. The provider documented recurrent evidence of social isolation and lack of engagement with others during her inpatient stay. Her self-care was impaired and she required assistance with showering. The patient showed consistent failure to maintain personal hygiene, appearance and self-care near usual standards. For dimension 3, the patient has severe comorbidities (score 5) as evidenced by her bradycardia, history of hypernatremia, and recent severe overdose attempt. The patients inability to comply with urine output requests placed her at imminent complications from these existing medical problems. She was a fall risk and was at risk of delirium. Her severe depression represented as a pseudo-dementia, pending formal neuropsychiatric testing and clarification. The patient had significant medical conditions that were poorly controlled and potentially life threatening in the absence of close medical management. For dimension 4A, the patients recovery environment was highly stressful (score 4) considering her loss of home, the recent death of her spouse, and inability to care for herself. The serious disruption of the patients family due to death, and severe disruption in life circumstances created a highly stressful recovery environment for the patient. For dimension 4B, the patients recovery environment was minimally supportive (score 4) with very few actual or potential sources of support available. The patient has children who are unable to care for her and she was discharged to a skilled nursing facility from the inpatient facility. For dimension 5, the patient showed minimal engagement and recovery (score 4) with poor response to previous and current treatment. The records suggest that the patient volitionally minimized or failed to recognize the severity of the symptoms leading to her suicide attempt, which occurred two days after a visit with her outpatient provider. Previous and current treatment has not achieved complete remission of symptoms or optimal control of symptoms even with intensive and repeated exposure. For dimension 6, the patient exhibited minimal engagement and recovery (score 4). The records document that she improved to this score by discharge from the inpatient level of care. The patient avoided contact with and use of treatment resources if left to her own devices. Moreover, she related poorly to treatment providers as evidenced by superficial responses and social withdrawal. This gives the patient a composite score of 29, which is consistent with medically managed residential services, such as inpatient psychiatric services. Given these findings, the patient met the LOCUS criteria for treatment at the inpatient level of care. Therefore, the inpatient psychiatric care was 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.