Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 38-year-old male enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric treatment from 4/17/18 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the documentation provided does not support the medical necessity of the services at issue in this clinical setting. The progress notes from the disputed period indicate that the patient was calm and cooperative. Psychiatric progress notes indicated the patient was adherent with his prescribed medications.  These progress notes indicated the patient was open to discussion of his past substance use as well as his current stressors. The patient did not exhibit any suicidal or homicidal ideation or signs of psychosis after the last covered date. According to the records, it does not appear that the patient needs inpatient psychiatric management at this time. He is not exhibiting dangerous behaviors towards himself or others and is fully cooperative in treatment. Based upon the documentation provided, the patient could receive his mental health treatment in a setting that is less restrictive than an inpatient psychiatric setting, due to his overall stable symptoms. He is not noted to have any severe mood swings or manic symptoms associated with his bipolar disorder. The references cited below indicate that patients with bipolar disorder may be treated outside of a hospital setting with the lack of mania or dangerous behavior, which appears to be the case with the patient and the stay under dispute. There is support, in the medical literature, for outpatient treatment with cognitive behavioral therapy as an effective modality for reduction in reoccurrence of manic symptoms associated with bipolar disorder. The Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services is an evidence based, objective, instrument in determining necessary level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. According to the LOCUS criteria, as of the first disputed date, the patients composite score is 18. A score between 17-19 correlates with a treatment intensity level of three.  Level three is described as High Intensity Community Based Services. According to this patients score on the LOCUS criteria, the level of treatment was not and is not medically necessary.  The patients risk of harm is scored a 2, mild. While the patient has a history of impulsive behaviors, there is a lack of current suicidal ideation. The patients functional status is scored a 3, (moderate) due to his inability to fulfill responsibilities and obligations. In the area of his medical, addictive and psychiatric co-morbidities, this is scored a 3, (moderate) due to substance issues with a lack of withdrawal symptoms. The patients recovery environment as it pertains to level of stress, is scored a 2, (mild) due to a potential for exposure to substances. The recovery environment as it pertains to level of support is scored a 3, (moderate) due to a stressful relationship with a parent. In the area of treatment and recovery history, this is scored a 3, (moderate). This is due to minimal treatment response in past. His engagement and recovery status is scored a 2, (positive) due to good cooperation in treatment and some current insight into need for treatment. Therefore, according to the LOCUS criteria this patient does not meet acute inpatient psychiatric treatment level of care. As such, acute inpatient psychiatric treatment from 4/17/18 forward was not and is not medically necessary. Based on the foregoing discussion, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.