Appeal type: Medical Necessity
Decision: Overturned

The patient is a female who was diagnosed with mixed bipolar disorder without psychotic features, major depressive disorder, and sedative hypnotic use disorder. The patient presented to the emergency department. She reported using a one-month supply of Ambien in two to three days. The patient endorsed stress at work and relationship difficulty with her husband. At the time of admission, she reported thoughts of self-harm and denied suicidal ideation. The patient was admitted to inpatient mental health treatment. The patient was noted to be tearful, depressed, and had suicidal ideation to overdose on medication. The patient was noted to be isolating in her room and not attending group therapy. She was noted to be depressed and anxious. She declined medication changes, and her insight and judgment were noted to be limited. The patient rated her depression as 10/10.  She reported suicidal ideation with a plan to overdose on Tylenol.  She reported poor sleep and concentration. The patient endorsed intermittent suicidal ideation. The patient reported feeling depressed and expressed suicidal ideation with a plan to overdose on Tylenol.  The patient was discharged from inpatient care to a partial hospital program. The patient has requested reimbursement for inpatient mental health treatment  that was provided through 5/2/19. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether inpatient mental health treatment was medically necessary for the treatment of the patients medical condition. The record indicates that during the time of treatment the patient was distressed, anxious, depressed and expressed suicidal ideation.  She was minimally cooperative in treatment, refused medication changes, refused therapy, and would isolate in her room. She expressed a plan to overdose on numerous occasions. The patient had relationship difficulty with her husband and parents. The patient endorsed recent abuse of Ambien. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm, the patients score is, due to active suicidal ideation with a plan to overdose on medication. For functional status, the patients score is, due to extreme deterioration in social interactions, including the patient endorsing that she took an unknown amount of Ambien in an attempt to shut herself down and become a zombie to get away from the stress for a few days. The patient also isolated in her room and reported feeling hopeless and wanting to take Ambien until she could not feel anything. For comorbidity, the patients score is, due to a recent history of substance abuse with Ambien. For recovery environment level of stress, the patients score is, due to a strained relationship with her husband and parents. For recovery environment level of support, the patients score is, due to no significant family support and conflictual relationships. For treatment and recovery history, the patients score is 5, due to minimal past treatment response to Abilify, Buspar, and Prozac. A poor treatment response with inpatient treatment was noted due to insolating behavior, refusal of medication changes, and continued suicidal ideation. For engagement and recovery status, the patients score is, due to refusal to attend therapy group sessions and making recommended medication changes. The patients composite LOCUS score is, which correlates with medically managed residential services. Medical evidence supports the services at issue in this clinical setting. Therefore, the requested inpatient mental health treatment that was provided was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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.