Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 38-year-old female enrollee has requested reimbursement for inpatient services from 5/30/17 through 7/14/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. Based on national guidelines, by 5/30/17, the patient could have received services at a lower level of care. To objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria is used. This is an accepted, national standard for determining the appropriate level of care for adults. On 6/1/17, the patient denied any suicidal or homicidal ideation. She was admitted due to impulsive and threatening behavior. She does have a history of excessive use of substances, particularly methamphetamine. As such, her risk of harm under the LOCUS criteria is 3, moderate risk. Her functional status is scored at a 3, moderate impairment. Upon admission, the patient had serious impairment in her functionality. She was refusing medications and had impairments in her ability for self-care. However, with treatment, the patient began to take medication and became compliant with treatment recommendations. Per documentation on 6/1/17, the patient was independent in her hygiene and self-care. The provider stated in his notes on 5/31/17 and 6/1/17 that the patient did not have any further psychotic symptoms and was not a danger to herself or others and that she was cooperative with treatment, but she is chronically disabled. As for her medical/addictive/psychiatric comorbidity, that is scored a 3, significant comorbidity.  The patient has a significant c-morbidity of schizophrenia, methamphetamine use disorder, and epilepsy. There were concerns at admission that the patient was abusing methamphetamine though the patient denied this on admission. Her recovery environment score, under the LOCUS criteria, is a 2, mildly stressful environment.  It appears that the patient lived independently prior to admission.   The patients parents are supportive of the patient. Thus, the patients level of support is scored a 2, supportive environment. Her treatment history is scored a 2 which falls under significant response to treatment and recovery. The patient has a chronic mental illness. When she is compliant with her medications, it appears that she is mentally stable and medically stable. She had a prior inpatient admission prior to the current admission. As for her engagement and recovery status, her score is a 3, limited engagement and recovery. At first, the patient was non-compliant, but on 6/1/17, the patient was cooperative with treatment. However, the patient would isolate and only interact with staff when necessary. This patients total score under the LOCUS criteria is 18. According to the LOCUS method, the patient would meet criteria for an intensive outpatient program. Based on the documentation, the initial reasons for admission were resolved by 5/30/17. Therefore, this patient could have been treated at a less restrictive environment as of 5/30/17. For these reasons, inpatient services from 5/30/17 through 7/14/17 were not medically necessary. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.