Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 38-year-old male enrollee has requested reimbursement for acute inpatient psychiatric treatment provided from 1/03/17 through 1/09/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the progress notes from the disputed period indicate that the patient was partially cooperative in treatment.  He began to refuse to take his psychotropic medication towards the end of his stay.  It did not appear that his refusal to take medication had any serious impact on his mental health symptoms.  On numerous occasions, he was noted to be at his baseline. The progress notes do not reflect severe psychiatric symptoms that necessitated inpatient treatment.  His continued stay appeared due to lack of placement options and a need for sobriety, not due to uncontrolled psychiatric symptoms requiring 24-hour psychiatric or nursing care. The patient did not express suicidal ideation or severe mood lability during the disputed period.  In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services is indispensable in determining necessary level of care for adults.  Based on this tool, the patients risk of harm was consistent with a score of 3.  The risk of harm was low due to a lack of current suicidal ideation.  The records support a score of 3 in terms of functional status.  The patient had an inability to fulfill responsibilities and obligations.  With regards to medical, addictive and psychiatric comorbidity, the records support a score of 3.  In terms of level of stress of the recovery environment, the records support a score of 2.  There was potential for exposure to substances.  In terms of level of support of recovery environment, the records support a score of 3.  The patient had a positive relationship with mother who cooperated in family therapy on a regular basis.  With regards to treatment and recovery history, the records support a score of 3.  There was minimal treatment response in the past. In terms of engagement and recovery status, the records support a score of 4. Thus, the patient has a composite score of 21.  A score of between 20 and 22 correlates with partial hospital program level of care. It appears that the patients main problems leading to his functional impairment were largely due to his alcohol use. The American Society of Addiction Medicine Adult Patient Placement Criteria for level of placement can be applied to the patients presentation to help determine the appropriate level of care. With regards to acute intoxication and/or withdrawal potential, the patient has a risk rating score of 0 due to lack of withdrawal. In terms of biomedical condition and complications, the patient has a risk rating score of 1 due to mild active medical problems. With regards to emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 2 indicating issues that are stable with a lack of suicidal ideation or severe mood or psychotic symptoms. In terms of readiness to change, the patient has a risk rating of 2 due to minimal motivation. With regards to relapse, continued use, or continued problem potential, the patient has a risk rating of 3 due to a minimal period of sobriety.  In terms of recovery/living environment, the patient has a risk rating of 3 due to a difficulty with sober placements. Overall, the patients presentation suggests risk rating scores in the range of 0 to 3.  This overall risk rating is consistent with clinically managed low intensity residential services, 24-hour structure with trained personnel, such as halfway houses. In sum, acute inpatient psychiatric treatment provided from 1/03/17 through 1/09/17 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.