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

  Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for residential treatment center (RTC) services. The enrollee has a history of depression, hallucinations, and suicidal ideation. He was admitted to a residential treatment center (RTC) on for alcohol and marijuana abuse. Findings:His daily use included beer, tequila, and vodka and one to two joints per day. He also smoked a half pack per day of tobacco for two years. He was unemployed and had been living in his car. He was started on Ativan protocol for detoxification and received medication management, individual counseling, group counseling, and medical appointments. The facility indicates the modified Ativan taper could not have been managed at an outpatient level of care. He was homeless and did not have a safe environment for discharge. He also lacked insight into his addiction, was unable to identify triggers for use, and had no known health coping mechanisms. On admission, the enrollee denied history of trauma or abuse, sleep disturbance or problems with appetite. He denied suicidal ideation, homicidal ideation or auditory verbal hallucinations. He denied depressed mood, mood swings or panic attacks, but reported anxiety. He denied pain or any medical problems. He wanted help for substance abuse, so he can find a job. He was put on modified Ativan protocol and Gabapentin and was monitored using Clinical Institute Withdrawal Assessment for Alcohol, CIWA-Ar-scale. Scores were between 0-9 (absent or minimal withdrawal). CIWA protocol was discontinued as score was 0. His vital signs were within normal limits during the entire stay. Labs were also normal. Urine toxicology screen was positive for cannabinoids. The enrollees risk of harm score is 2, low risk since he has no current suicidal or homicidal ideation, plan, intentions or severe distress. Substance use is without significant episodes of potentially harmful behaviors. Functional status score is 3, moderate impairment. The enrollee is becoming troubled in most significant relationships, but maintains control of any impulsive or abusive behaviors. His appearance and hygiene fall below usual standards on a frequent basis. He has significant deterioration in his ability to fulfill responsibilities and obligations to job and self. Also, he has chronic and/or variably severe deficits in interpersonal relationships, ability to engage in socially constructive activities, and ability to maintain responsibilities. His comorbidity score is 2, which is minor; he may occasionally experience psychiatric symptoms which are related to stress, or substance use, but which are transient and have no discernable impact on the co-existing substance use disorder. Recovery environment is 3, which is moderately stressful. He has significant discord or difficulties in his family or other important relationships or alienation from social interaction.  He has experienced significant transition causing disruption in his life circumstances including job loss, or change of residence, homeless at time of admission. He has experienced recent important loss or deterioration of interpersonal or material circumstances. He has easy exposure and access to alcohol and drug use. His level of support is 3, with limited support in his environment. He has a few supportive resources in his current environment that may be capable of providing some help, if needed.  His usual sources of support have a limited amount of resources they are willing or able to offer when needed. Treatment and recovery history score is 3 as he has a moderate or equivocal response to treatment and recovery management. He has not achieved complete remission of symptoms or optimal control of symptoms. Engagement score is 3 as he uses resources only when in extreme need. Review of the record indicates a total score of 19, which correlates with high intensity community-based services. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.