Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 22-year-old male enrollee has requested reimbursement for partial hospitalization from 8/31/15 through 10/22/15. 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 of the services at issue in this clinical setting. To objectively determine if the patient meets criteria for length of stay, the Level of Care Utilization System (LOCUS) criteria is utilized. This is an accepted, national standard for determining the appropriate level of care for adults.  According to the LOCUS criteria, on 8/31/15, the patients risk of harm was scored a 3 which correlates to a moderate risk of harm. The patient has a history of suicide attempts. He attempted to hang himself and overdose on medications. He also had homicidal thoughts of going to his school and harm to others. He denied any suicidal ideation or homicidal ideation on 8/31/15. The patients functional status is scored a 3, moderate impairment.  The patient has a history of serious impairment through his substance use. He dropped out of college and lost his job. He ended up in jail for 30 days after verbally threatening to stab a man. However, the patient had eight months of sobriety and has made progress. He continued to have symptoms of depression, anxiety, and paranoia and had interpersonal problems with his parents. As for his medical, addictive, and psychiatric comorbidity, his score is a 3, which correlates to significant comorbidity. The patient had a comorbidity of bipolar disorder and polysubstance abuse. The patient did not have any serious medical problems. His recovery environment is scored a 2, mildly stressful environment. It appears that the patient had left a sober home environment and was living alone. The patients level of support is scored a 2, which correlates to a supportive environment. The patients parents are supportive of the patient. His treatment history is scored a 2, significant response to treatment. The patient has been attending Alcoholics Anonymous and participating with a sponsor. He had eight months of sobriety. He continued to have some symptoms of depression, anxiety, and paranoia. The patients engagement and recovery status is scored a 2, which correlates to positive engagement and recovery. The patient has a strong desire to remain sober. He participated in groups and treatment. According to the LOCUS criteria, the patients total composite score is 17 and would have met criteria for an intensive outpatient program. The patient continued to require treatment for his bipolar disorder, anxiety, depression, emotional dysregulation, and polysubstance abuse. However, this could have been performed in a less restrictive environment. In sum, partial hospitalization level of care from 8/31/15 through 10/22/15 was not medically necessary for the treatment of this patients medical condition.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.