Appeal type: Medical necessity
Decision: Upheld

This patient was admitted for treatment of pain; per the denial letter, he was admitted to the facility for the treatment of depression. It was noted that he may progress and his condition no longer meets guidelines for recovery for treatment in this level of treatment. The patient did not have any new medical issues. He was active in his treatments and has been taking medications. His symptoms were better. He was able to continue care in the mental health partial hospitalization setting rather than this residential setting. This decision was made by guidelines and policies by the insurance plan. Therefore, it was determined that no further authorization can be provided.
A discharge document indicates that he has diagnosis of generalized anxiety disorder (GAD) and two more diagnoses, which were illegible. He was admitted. The reason for hospitalization was pain, appetite decrease, and anxiety. His treatment was completed and he was medically and psychiatrically stable for discharge.  He was seeking treatment for his chronic pain and he was given multiple tests administered. His diagnostic impressions includes GAD, specified trauma and stress-related disorder, unspecified depressed disorder, unspecified personality traits, relationships stress with spouse, and psychological factors affecting other medical conditions (chronic pain). Recommendations include individual and group therapy and psychoeducation lectures along with continued residential treatment to receive pain services and management.
Follow-up notes indicate that he was seen for pain, opioid dependence and Crohn's disease. He reports pain under control, anxiety level is low, and he is aware of stressors in resolving conflicts with his spouse. He also talked about stress in the workplace. He was given medication adjustments to have better control of his pain along with biofeedback. He was provided physical therapy.
The discharge summary indicates he was admitted for treatment of pain. He has diagnoses of Crohn's disease and pancreatitis. He had no past psychiatric history. His substance use history includes using opioids for pain and he reports using as ordered. Similarly, he has been using a benzodiazepine as ordered. He required active psychiatric treatment that includes 24 hours access to prospective psychiatric staffing. Indication for treatment at this level of care was opioid dependency. He was admitted for detox and lower level of care would be unsafe. He stopped Suboxone and was having symptoms of withdrawal.
This patient was admitted to the program for ongoing chronic pain and opioid dependency. He reported no other substance use disorders. His opioid use was not at a level of misuse or abuse. He reportedly has been taking his prescribed medications as directed. During his stay, he was provided counseling for his other psychosocial stressors including conflicts with his spouse and work-related stressors. He also was treated with Suboxone for his pain, which can be done successfully in the outpatient settings. He was provided physical therapy, which also can be arranged in the outpatient settings. Therefore, there is no medical necessity for this patient to be treated at the requested level of treatment of residential care since his symptoms improved significantly and under control with recommended medications and other therapies. At issue is the medical necessity of mental health residential services .
The health plan's determination is upheld.
The patient was admitted for treatment of pain. He has diagnoses of Crohn's disease and pancreatitis. He had no past psychiatric history. His substance use history includes using opioids for pain and he reports using opioids as ordered. Similarly, he has been using a benzodiazepine as ordered. It was noted that he required active psychiatric treatment that includes 24 hours access to prospective psychiatric staffing, however, documents do not indicate any acute psychiatric condition that needs to be treated at this level.
On admission, it was noted that indication for treatment at this level of care was opioid dependency, and he was admitted for detox and lower level of care would be unsafe. However, per notes, he has been using his opioid medications as recommended.
Per Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) criteria, the patient's condition does not meet residential services, since the patient did not have any new medical issues.  He was active in his treatments and has been taking medications.  His symptoms were better.  He was able to continue care in the mental health partial hospitalization setting rather than this residential setting.   Therefore, services for  are not medically necessary.