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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment center (RTC) services.With regard to dimension 1, the patient is experiencing significant post acute withdrawal symptoms which could be adequately be met at this level of care. Per the records, he continued to experience mild to moderate withdrawal. The patients Clinical Institute Withdrawal Assessment (CIWA) score was 12, and he was experiencing tactile hallucinations, paroxysmal sweats, agitation, anxiety, auditory disturbances and tremor. The records indicate that the patient had also been abusing Librium, a very long acting benzodiazepine, which places him at further risk of relapse outside of the 3.5 level of care setting. In terms of dimension 2, the patients mental status was sufficient to permit participation in the therapeutic interventions provided at this level of care. Although there was a history of a suicide attempt while intoxicated prior to his admission to this residential treatment center, his psychiatric needs do not require inpatient admission and may be managed at the 3.5 level of care. Despite his best efforts, the patient is unable to control his alcohol use without the attendant probability of imminent danger. This is illustrated by his impulsive and dangerous behavior while intoxicated. Such behavior places him, and perhaps others, at risk of harm. With regard to dimension 3, the patients status is characterized by the range of psychiatric symptoms that require active monitoring. Although he does not need one-to-one observation, he has had increased safety checks by staff given his categorization as chronic high risk for suicide. This patient is statistically at high risk for suicide since he had a recent suicide attempt prior to his admission. The patient struggled with significant posttraumatic stress symptoms. The 24-hour milieu in this 3.5 level of care setting is sufficient to contain his impulses, and he required a strength-based and focused treatment regimen to manage his impulses.In terms of dimension 4, the records document chronicity of his substance use disorder. His limited insight, in combination with his need for treatment for his posttraumatic stress disorder, depression, anger and anxiety, can be safely met at this level of care. He is also in the process of a divorce, and has limited interaction with his children. With regard to dimension 5, the patient is experiencing psychiatric symptoms, including posttraumatic stress disorder symptoms of hyperarousal, isolation, dissociative symptoms, feelings of rejection and abandonment, insomnia, depression, intermittent suicidal ideation and insomnia. He also has intense cravings to use and has scored elevated on the CIWA. In terms of dimension 6, the patients social network is characterized by significant social isolation and withdrawal. He is also in the midst of a divorce and is not able to see his children as often as he would like. He is unable cope, even for limited periods of time, outside of this 24-hour level of care. He needs staff monitoring to learn to cope with this dimension of problems prior to safely being transferred to a less intensive setting.All told, criteria for 3.5 level of care were, and are, met and continued residential treatment center care at this level is recommended. Therefore, the mental health residential treatment center (RTC) services at issue and requested services were, and are, medically necessary to treat the patients mental health condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patients mental health condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in addiction 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.