Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. Based on the clinical evidence presented for review, the presence of psychosis, paranoia, suicidality, homicidal ideation, or medical instability in this patient would in fact represent exclusionary criteria for residential placement. An unstable medical condition and/or presence of an acute psychiatric syndrome, such as posing threat of harm to oneself or others, would warrant service delivery in a higher level of care such as an inpatient psychiatric or medical psychiatric unit. Further, participation in programming certainly demonstrates motivation for recovery and bodes well for the likelihood of continuation in less restrictive settings, but attending all groups is an unreliable independent marker for discharge appropriateness, as it fails to incorporate the nature of engagement and extent of the illness burden. The American Society of Addiction Medicine recommends placement determination based on a complex individual clinical assessment, rather than reimbursement limitations, program ideology, or utilization reviewers. The American Psychiatric Association recommends residential treatment for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this particular case, the patients poly-substance use was dominating a daily routine and contributing to significant impairment across multiple domains of functionality. The patients unabated drug use was straining relationships with friends and family, impairing employability, compromising health, and contributing to self-defeating if not illegal behaviors. Upon presentation, the patients motivation for sobriety was low. The patient had little discrimination for the substance that facilitated intoxication. The medical documentation shows that the patient had not consolidated the treatment gains necessary to succeed in the outpatient setting and promptly would have relapsed in a community-based setting if discharged. The patient had poor appetite and was going through changes in medication regimen. In sum, the patient was symptomatic and at high-risk for relapse. Thereafter, the records indicate that the patient was actively engaged in treatment until the day of discharge. The services and setting were safe, appropriate and consistent with good practice in the United States. Additionally, the services provided at the time were reasonably expected to improve the patients condition and prevent a more serious episode of illness while a less restrictive setting would have been inadequate at the time. Considering the clinical presentation and perusal of the relevant peer-reviewed literature, the residential treatment center services provided were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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.