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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient psychiatric hospitalization. Findings:  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. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to a recent pattern of excessive cannabis use resulting in loss of self-control and harmful behaviors without a demonstrated ability to abstain from use. The patient had recently been arrested for driving under the influence (DUI), was psychotic, and on a rooftop prior to hospitalization. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to the presence of psychosis. The patient met the criteria of having a serious decrease in the quality of interpersonal interactions with consistently conflictual or otherwise disrupted relations with others, which may include impulsive, aggressive or abusive behaviors, and an inability to perform close to usual standards in school, work, parenting, or other obligations and these responsibilities may be completely neglected on a frequent basis or for an extended period of time.With regard to comorbidity, the records support a score of 4. The patient had major comorbidity due to the presence of severe substance use comorbid with underlying psychotic illness and a possible mood disorder. The patient met the criteria of having uncontrolled substance use at a level that posed a serious threat to health if unchanged, and/or which posed a serious barrier to recovery from any co-occurring psychiatric disorder, and psychiatric symptoms which were clearly disabling and which interacted with and seriously impaired her ability to recover from any co-occurring substance use disorder.In terms of level of stress of the recovery environment, the records support a score of 4.  The patient had a highly stressful environment due to a severe disruption in life circumstances such as going to jail, losing housing, or living in an unfamiliar, unfriendly culture as she was recently incarcerated for a DUI. The patient was unable to meet her needs for physical and/or material wellbeing.With regard to level of support of the recovery environment, the records support a score of 4 as the patient was unwilling to use supports available in a constructive manner. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment and recovery management as she had been hospitalized previously and had been gravely ill in recent months. The patient met the criteria of previous or current treatment not achieving complete remission of symptoms or optimal control of symptoms even with intensive and/or repeated exposure, and limited success with attempts to maintain whatever gains were attained in intensive treatment, even for limited time periods or in structured settings.  With regard to treatment acceptance and engagement, the records support a score of 4. The patient was rarely, if ever, able to accept the reality of her illness or any disability that accompanied it, although she may have acknowledged some difficulties in living. She had no desire or was afraid to adjust behavior, although possible recognizing the need to do so. She related poorly to treatment and treatment providers. Her ability to trust was extremely narrow, and she avoided contact with and use of treatment resources if left to own devices.Thus, the patient has a total score of 28. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care was medically managed residence-based services. In this patients case, inpatient level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, inpatient psychiatric hospitalization were medically necessary for the 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.