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

Nature of Statutory Criteria/Case Summary: The enrollee's parent has requested reimbursement for the residential treatment center (RTC) level of care for substance abuse and mental health services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that the records indicate that the patient was cooperative with the providers and his activities of daily living remained intact. The medical records do not document active suicidal ideation or psychosis during the disputed period. The documentation indicates that the patient was functioning well at the RTC. Initial progress notes indicate he had almost no motivation to change his behavior. However, as his treatment progressed, the patient was noted to be begin to realize that he had issues that needed treatment. The majority of the treatment progress notes focused on the patients relationship with his family. It appears that much of the treatment was focused on the possible improvement of family relationships. The treatment progress notes did not focus on substance use or mental health symptoms. The patient was not displaying any signs of psychosis, self-harm behavior, or aggression towards others. He was cooperative with reading the materials for his treatment. It is noted that he had minimal prior treatment and the records do not reflect any treatment in an intensive outpatient program (IOP) or partial hospital program (PHP). It is also noted that the patient was able to remain sober when he was on probation. He had no active serious medical problems and no symptoms of substance withdrawal. The American Society of Addiction Medicine (ASAM) for level of placement can be applied to this patients presentation to help determine the appropriate level of care for the patient. The patient presented with a risk score of (0) due to lack of withdrawal, a biomedical condition and complications score of (0) due to no serious medical condition, and a score of (3) for emotional/behavioral or cognitive conditions and complications due to mild depression issues that are stable. The patient has a risk rating score of (2) due to apparent motivation and readiness to change. The patient demonstrated a minimal recent period of sobriety with a score of (2), and a risk rating score of (1) due to a supportive and sober living environment with family but with significant relationship issues. Overall the patients presentation included risk rating scores in the range of 0 to 2. This overall risk rating places the patient at a level of care according to the ASAM criteria which is consistent with IOP services for nine or more hours per week. Overall, the records indicate that the patient could have been treated in a less restrictive setting safely and effectively and did not have severe symptoms that necessitated 24-hour level of supervision. In summary, the RTC level of care for substance abuse and mental health services provided were not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in child and adolescent 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.