Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) risperidone (Risperdal), and (2) inpatient psychiatric hospitalization services for a minimum of 30 days and up to 90 days at a facility that specializes in paranoid schizophrenia with negative affect and bipolar disorder. In treating patients with psychosis, the determination of the antipsychotic and treatment plan should be in a shared decision making model between the patient and the clinical team. In this case, the patient has been noncompliant with and resistant to taking medications. Given that the patients current psychiatric treatment team is not recommending treatment with risperidone and the patients refusal of medications, the requested medication is not medically indicated. In this patients case, risperidone is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration.  Therefore, (1) risperidone (Risperdal) is not medically necessary for the treatment of this patient.At issue is whether (2) inpatient psychiatric hospitalization services for a minimum of 30 days and up to 90 days at a facility that specializes in paranoid schizophrenia with negative affect and bipolar disorder medically necessary for treatment of the patients mental health or substance use disorder for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care, (ii) clinically appropriate in terms of type, frequency, extent, site, and duration, and (iii) 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.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. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to reported statements of suicide and homicidal ideation.  The records noted a pattern of excessive substance use resulting in loss of self-control and harmful behavior with very limited ability to abstain from use except while in a treatment setting. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment as the patient is currently homeless and unable to meet usual standards of functioning. With regard to comorbidity, the records support a score of 4. The patient has major comorbidity due to the presence of uncontrolled substance use posing a serious threat to health if unchanged and a serious barrier to their recovery from depression and psychosis. The patient repeatedly becomes floridly psychotic and depressed in the context of drug use and is unable to control their use outside a treatment setting.  In terms of level of stress of the recovery environment, the records support a score of 4.  The patient has a moderately stressful environment as they are homeless due to their substance use and is unable to meet their own physical needs.With regard to level of support of the recovery environment, the records support a score of 3 as the patients supports are their mother and aunt, whose resources to support the patient physically and emotionally have been exhausted. When engaged, the patients resources are able to assist and are quite supportive.  In terms of resiliency and treatment history, the records support a score of 4. The patient has poor response to treatment and recovery management, with their only recovery attained in the context of highly structured settings like inpatient psychiatric units, and an inability to maintain those gains outside of intensive treatment.  With regard to treatment acceptance and engagement, the records support a score of 4. The patient avoids contact with and use of treatment resources if left to their own devices, with difficulty accepting responsibility for recovery. Thus, the patient has a total score of 27. The records support a 4 in terms of risk of harm, functional status, and comorbidity. In this case, the recommended level of care is medically monitored residence-based services. In this patients case, inpatient psychiatric hospitalization is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, (2) inpatient psychiatric hospitalization services for a minimum of 30 days and up to 90 days at a facility that specializes in paranoid schizophrenia with negative affect and bipolar disorder are not medically necessary for the treatment of this patient..Final Result: The reviewer determined that the requested medication and services are 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.