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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Based on review the records provided for review, the patients presentation was consistent with CIWA and COWS scores of zero on admission. The patients blood pressure was 94/54 and she did not report any withdrawal symptoms. The patient has been performing ADLs and does not have any delusions or hallucinations. She has demonstrated an appropriate affect and depressed mood. The patient has been cooperative with care and is actively involved in her treatment. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient does not meet the criteria for RTC level of care. For dimension 1, acute intoxication and/or withdrawal, the patient is at low risk. For dimension 2, biomedical conditions or complications, the patient scores low. For dimension 3, emotional/behavioral or cognitive conditions and complications, the patient is high. Dimension 4, readiness to change is moderate. Dimension 5, relapse, continued use or continued problem potential is high. Dimension 6, recovery environment is low risk. These findings suggest the patient is a candidate for treatment in a less restrictive treatment setting than RTC. 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. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In terms of risk of harm, the records support a score of one due to no suicidal ideation and a history of self-harming behaviors. With regard to functional status, the records support a score of two due to some minimal or mild impairment with comorbidity. In terms of medical, addictive and psychiatric comorbidity, the records support a score of two due to overall medical stability. In terms of level of stress of the recovery environment, the records support a score of two due to a low to mild stressful environment. With regard to level of support for the recovery environment, the records support a score of three due to limited family support and availability of treatment resources but also some difficulty in relationships with her family members. With regard to treatment and recovery history, the records support a score of three due to mild to moderate success at the RTC level of care. In terms of engagement and recovery status, the records support a score of two. This gives the patient a composite score of 15, which is consistent with treatment in an outpatient venue. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment for patients with this level of impairment. Therefore, the RTC services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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.