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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center (RTC) services for alcohol use disorder. The enrollee was admitted following the death of a friend from alcohol poisoning. This incident triggered a substantial increase in his alcohol use and some post-traumatic stress disorder (PTSD) - like symptoms. The enrollee was highly motivated to focus on sobriety and grief work, which became part of his treatment plan. He attended meetings and established a recovery community. He was advised not to move directly out on his own after discharge. Recommendations were made for transfer to a sober-living environment to assist with transition into a normal life routine. However, the enrollee chose not to go. The discharge note rates his prognosis as guarded due to his tendency to prioritize personal relationships and comfort above the needs and purposes of recovery.  His level of commitment to recovery is unclear and without a full commitment towards this goal, it is noted he will likely relapse. The Level of Care Utilization System (LOCUS), was applied in review of the records. For risk of harm, the enrollees score is 2, because he has no current suicidal or homicidal ideation, plan, intentions or severe distress. For functional status, the enrollees score is 3, due to recent gains or stabilization in function achieved while participating in treatment in a structured and /or protected setting. He stops drinking for a short period of time and can attend work, but he relapses without participation in a treatment program. For comorbidity, the enrollees score is 3, because he has significant psychiatric symptoms and signs. These symptoms are somewhat debilitating, and can interact with and have an adverse effect on the course and severity of any co-existing substance use disorder. For recovery environment level of stress, the enrollees score is 3, due to easy exposure and access to alcohol and drugs. For recovery environment level of support, the enrollees score is 3, because his usual sources of support may be somewhat ambivalent, alienated, and difficult to access, or have a limited amount of resources they are willing or able to offer when needed. For treatment and recovery history, the enrollees score is 2, due to past sobriety for moderate periods of time with limited support. For engagement and recovery status, the enrollees score is 3, because previous treatment exposures have been marked by minimal effort or motivation and no significant success or recovery period was achieved. The enrollees composite LOCUS score is 20, which correlates with medically monitored non-residential 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.