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

An enrollee has requested authorization and coverage for continued stay at an inpatient psychiatric facility.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- Risk of Harm. This dimension assesses potential for harm to self or others. The patient has schizoaffective disorder and has a history of suicidal ideation and aggression towards others including his family, staff, and police. The patients younger twin siblings had a restraining order against him after he punched them. The patient reported suicidal ideation after his release from jail and he was noted to be hitting his head against the wall while in the emergency department. Since his admission to the inpatient unit, the patient is not reporting any suicidal ideation or homicidal ideation. Therefore, while no active suicidal or homicidal ideation has been noted, extreme distress and/or a history of suicidal/homicidal behavior exists. [Score 3  moderate risk of harm]For dimension 2  Function. This dimensions assesses the degree to which a person is able to fulfill social responsibilities, interacts with others, and maintains physical functioning and capacity for self-care. Due to the patients chronic mental illness, he receives SSI and has not been working in years. He has had significant deterioration in his ability to fulfill responsibilities and obligations. He has had significant disturbances with his family members such that his mother will not allow him to live with them. As he has long outstanding deficits and he is described as being at baseline level of functioning, he has moderate impairment. [Score 3  moderate impairment]For dimension 3  Comorbidity. This dimension 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 has significant co-morbidity due to his substance usage of alcohol and recent diagnosis of B12 deficiency that requires intramuscular dosage and workup on an outpatient basis. The patients prior daily usage of alcohol has had clearly detrimental effects on his psychiatric stability and has been temporarily arrested after incarceration and hospitalization. [Score 3- significant co-morbidity]For Recovery Environment dimension 4A- Stress. This dimension assesses the stressors in the patients environment, social circumstances, and interpersonal relationships. The patient has a moderately stressful recovery environment due to significant disruption in his life circumstances with recent incarceration and loss of housing as well as significant discord with family members due to his psychiatric illness and history of aggression towards them. [Score 3 moderately stressful environment]For Recovery Environment dimension 4B- Support. This dimension assesses the presence of family and social support to augment the patients recovery environment. The patient has only met with his prior outpatient psychiatrist once. His mother has conservatorship over him. He is also not able to live at home as his younger siblings have a restraining order against him. [Score 3- limited support in environment]For dimension 5- Treatment and Recovery History. This dimension assesses how past experiences with treatment and recovery might indicate how the patient might respond in the future. The patient has had multiple medication trials and had trouble with both efficacy and tolerability. He has had multiple inpatient hospitalizations with little sustained improvement. Previous treatment has not achieved complete remission or optimal control of symptoms even with repeated exposure. [Score 4- poor response to treatment and recovery management]For dimension 6  Engagement. This dimension assesses a persons understanding of their illness and treatment, and their ability and willingness to engage in the treatment process. The patient does not feel that he has a psychiatric illness that is in need of treatment. It also appears that he would not be in treatment if his mother did not have conservatorship of him. [Score 4- minimal engagement and recovery]These findings give the patient a composite score of 23, which corresponds with Level 5, Medically Monitored Residential Services. Level 5 is consistent with a residential treatment center (RTC) level of care. Accordingly, continued stay at an inpatient psychiatric facility is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.