Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 20-year-old male with a past psychiatric history of intermittent explosive disorder and attention deficit hyperactivity disorder. The patient has requested reimbursement for acute psychiatric inpatient treatment provided from 11/03/21 through 11/13/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is this subject of this appeal and determination. 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 and recovery status. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient met the criteria for acute psychiatric inpatient services provided from 11/03/21 through 11/13/21. For dimension 1, risk of harm, the records support a score of 5. This dimension assesses potential for harm to self or others, or having harm inflicted upon them. The patient was noted to be unsafe outside of the community. He had poor insight, erratic judgment, and was described as highly explosive. He was involuntarily committed to the inpatient psychiatric facility during the period under review. The patient had been endorsing homicidal ideation. He was described as impulsive. For dimension 2, functional status, the records support a score of 5. This dimension assesses the degree to which a patient is able to fulfill social responsibilities, to interact with others, maintain physical functioning, as well as a patientas capacity for self-care. The records indicate that the patient had been threatening others, was argumentative, was disruptive in the milieu, had engaged in property destruction, and was easily agitated and impulsive. He was isolative from family members. At the time of admission, the patient self-reported that he engaged in property destruction. He also engaged in threatening behavior. For dimension 3, medical, addictive, and psychiatric comorbidity, the records support a score of 2. This dimension assesses the potential complications in the course of illness due to level of acuity or disability related to co-occurring medical illness, substance use disorder, or psychiatric disorder in addition to the presenting disorder. Although the patient denied substance use, his urine toxicology on admission was positive for cannabis. For dimension 4A, level of stress in the recovery environment, the records support a score of 4. This dimension assesses the stressors in the environment, social circumstances, and interpersonal relationships. The patientas recovery environment is highly stressful due to significant conflict with family members as a result of his irritability and poor anger control. The family feels as though they awalk on eggshellsa due to the patientas behavior. For dimension 4B, level of support in the recovery environment, the records support a score of 2. This dimension assesses the resources which enable the individual to maintain health and role functioning, such as availability of adequate material resources, relationships with family members, and the availability of friends, employers, teachers, or others. According to the records, the patientas mother appears to be supportive as evidenced by her willingness to engage with the patientas treatment providers by providing them information about the patient. The patient described his family as supportive. For dimension 5, treatment and recovery history, the records support a score of 5. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. In this patientas case, prior treatment has included weekly psychotherapy, regular psychiatric visits, and psychotropic medication for the last four years. In addition, the records noted one previous inpatient psychiatric admission for similar issues, and he attended a partial hospital program. He had also not responded to the structure and containment of the current hospital milieu. Despite this, the patientas symptoms persisted, and his functional ability has shown no significant improvement. Per the records, the patient has had negligible response to treatment. For dimension 6, engagement and recovery status, the records support a score of 5. This dimension considers a patientas understanding of illness and treatment and ability or willingness to engage in the treatment and recovery process. According to the records, the patient had been refusing medication. He minimized his symptoms and had little insight into his mental illness. These findings give the patient a composite score of 28, which is consistent with Level 6 Medically Managed Residence Services. Per LOCUS, the patientas scores of 5 for risk of harm and functional status also support treatment at Level 6 Medically Managed Residence Based Services level of care. Therefore, acute psychiatric inpatient treatment provided from 11/03/21 through 11/13/21 was medically necessary for the treatment of this patient.