Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 32-year-old female with major depressive disorder. The patient has requested 
reimbursement for adult inpatient behavioral health continued stay from 6/02/21 through 
6/14/21.  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 adult 
inpatient behavioral health continued stay from 6/02/21 through 6/14/21. For dimension 1, risk 
of harm, the records support a score of 5. This dimension assesses potential for harm to self or 
others. The patient was admitted after a serious, potentially lethal suicide attempt by hanging 
and with continued suicidal ideation throughout the hospitalization even toward the end of 
treatment. For dimension 2, function, the records support a score of 5. This dimension assesses 
the degree to which a person is able to fulfill social responsibilities and maintain physical 
functioning and capacity for self-care. Due to the patients severe, refractory depression, she was 
withdrawn and avoided social interactions, even during her hospitalization. She was not able to 
perform close to her usual standards in work, necessitating medical leave. For dimension 3, 
comorbidity, the records support a score of 3. 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 a history of symptoms of 
hypoglycemia, which is complicated by the need to be NPO for electroconvulsive treatments. 
Additionally,  the  patient  was  quite  disoriented  and  with  cognitive  deficits  following 
electroconvulsive  therapy  treatments.  For  dimension  4A,  level  of  stress  of  the  recovery 
environment, the records support a score of 4. This dimension assesses the stressors in the 
environment,  social  circumstances,  and  interpersonal  relationships.  The  patient  has  had 
significant discord in her marriage. The patient felt an overwhelming demand to meet immediate 
obligations in terms of her job and her marriage and was unable to meet these demands. For 
dimension 4B, level of support of the recovery environment, the records support a score of 3.  
This dimension assesses the presence of family and social support to augment the recovery 
environment. The patient has had marital discord, limiting the support available from her 
husband. She relied heavily on her parents for support. For dimension 5, treatment and recovery 
history, the records support a score of 4. This dimension assesses how past experiences with 
treatment and recovery might indicate how the patient might respond in the future. The patient 
has been in outpatient treatment since 2013 with refractory course of depression and failure to 
achieve remission of symptoms. For dimension 6, engagement, the records support a score of 4. 
This dimension assesses an individuals understanding of his or her illness and treatment, and 
ability and willingness to engage in the treatment process. Due to severity of her symptoms, this 
patient avoided contact with treatment resources if left to her own devices, immediately isolating 
when depression worsens and suicidal ideation resumes. These findings give the patient a 
composite score of 28, which is consistent with medically managed residence-based services or  inpatient psychiatric hospitalization. Per LOCUS, the patients scores of 5 for functional status 
and risk of harm also support treatment at Level 6 medically managed residence-based services 
level of care. For these reasons, the psychiatric inpatient hospitalization services from 6/2/21 
through 6/14/21 were medically necessary for treatment of this patient.