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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospital services.Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder.The progress notes indicate that the patient was not an immediate danger to self or others. He denied suicidal and homicidal ideation and was not exhibiting self-injurious behavior, aggression or homicidal thoughts. The progress notes do not indicate that he was unable to provide for or utilize food, shelter, or clothing due to his mental disorder. The records do not document that the services at issue were needed to treat or diagnose a psychiatric emergency medical condition. The patient did not display significant symptoms that warranted emergency treatment or evaluation according to a Health and Safety Code. Therefore, inpatient hospital services were not emergency services as defined by California law.In cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 2 due to a lack of current suicidal ideation but a history of past suicidal behavior. In terms of functional status, the records support a score of 3 due to overall good daily functioning while in the inpatient unit but consideration of past issues. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to a recent history of substance use and no unstable medical problems. In terms of level of stress of the recovery environment, the records support a score of 3 due to mention of recent sober living and support system. With regards to level of support of the recovery environment, the records support a score of 2 due to involvement of family in treatment. In terms of treatment and recovery history, the records support a score of 3 due to apparent good response to recent intensive outpatient program and inpatient treatment but also consideration of recent substance relapse. With regards to engagement and recovery status, the records support a score of 2 due to good cooperation in treatment and noted insight into need for treatment. Thus, the patient has a composite score of 17.   This score correlates with high intensity, community-based services. Thus, inpatient level of treatment was not medically necessary. Therefore, inpatient hospital services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.