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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center (RTC) services received. Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria for level of placement is appropriate to determine the necessary level of care for the patient. With regard to acute intoxication and/or withdrawal potential, the patient had a risk rating score of 0 due to lack of withdrawal, for biomedical condition and complications the patient had a risk rating score of 0 due to no active medical problems, and emotional/behavioral or cognitive conditions and complications includes a risk rating score of 1 indicating mild issues that were stable. Given the patients readiness to change, he had a risk rating of 2 due to some apparent motivation, for relapse, continued use, or continued problem potential, the patient had a risk rating of 1 due to a minimal period of sobriety, and for recovery/living environment, the patient had a risk rating of 2 due to living environment with some substance use. Overall, the patients presentation suggests risk rating scores in the range of 0 to 2. This overall risk rating places the patient at a level 2.1 of care according to the ASAM criteria, which is consistent with intensive outpatient program (IOP) services, nine or more hours of service per week. The evidence base surrounding IOP treatment indicates that IOPs are an important part of the continuum of care for alcohol and drug use disorders. They are as effective as inpatient treatment for most individuals seeking care. The evidence base for adolescent cannabis treatment indicates that cognitive behavioral therapy (CBT) performed on an outpatient basis is effective for the treatment of this disorder. The records indicate that the patient was cooperative with staff and his activities of daily living appeared intact. The medical records do not support active suicidal ideation or psychosis during the disputed period. There were no significant or severe behavioral problems noted during his stay. The patients intake assessment does not indicate that he had tried or failed any substance abuse treatment. His overall past behavioral health treatment was minimal and included approximately 10 outpatient therapy sessions and a few psychiatric appointments. The patient had not reportedly attempted outpatient CBT and it seems that this would have been a viable option for him due to lack of overall safety concerns. Overall, the patient could have been treated in a less restrictive setting safely and effectively. Thus, the RTC services provided for the dates of service in question 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.