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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment from 10/12/17 to 11/1/17 and partial hospitalization program (PHP) services from 11/2/17 to 12/22/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay by moving from program-driven to clinically driven and outcomes-driven treatment. In this patients case, the date of last use of any substance was on 10/05/17, and he had undergone detoxification while in jail prior to admission to residential treatment center on 10/11/17. At the time of admission, the patient was experiencing moderate post-acute withdrawal symptoms. He was not a danger to himself or others, nor was he aggressive or violent. The patient was cognitively intact, and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms to warrant residential level of care.  The patient was medically and psychiatrically stable. He was placed on a medication regimen of Zoloft, Seroquel, gabapentin, Melatonin, and medication assisted treatment (buprenorphine taper). This could have been performed in an outpatient setting. Standard of practice dictates that he could have safely undergone buprenorphine induction on an outpatient basis, followed by buprenorphine maintenance to prevent pain, cravings and subsequent relapse. The patient could then have been treated at that point in an ambulatory setting to work on relapse prevention skills, the development of coping mechanisms, and participate in a 12-step program, especially given his description of being highly motivated and having a supportive family to help him in his efforts. The patient did not require admission to residential treatment on 10/11/17. He could have safely been treated at intensive outpatient level of care. Residential services were not medically necessary from 10/12/17 through 11/1/17. With regards to the request for partial hospitalization program level of care from 11/02/17 through 12/22/17, by that point the patient could have safely been transitioned to outpatient level of care. Therefore, residential treatment from 10/12/17 to 11/1/17 and partial hospitalization program (PHP) services from 11/2/17 to 12/22/17 were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services 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.