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 services. He has a history of anxiety, depression, alcohol and substance abuse and was admitted to residential care for detoxification. He has a history of detox/residential treatment; twice as an adolescent and recently as an adult. Progress notes from discharge show the enrollee with appropriate affect, an angry and irritable mood, with fair judgment, and no suicidal/homicidal ideation. A physical assessment note documented his appetite as good, with no tremors, headache, or nausea and vomiting.  According to the LOCUS system, for risk of harm, the enrollees score is 2, because he has a history of substance use without significant episodes of potentially harmful behaviors. For functional status, the enrollees score is 3, due to chronic and variably severe deficits in his interpersonal relationships, his ability to engage in socially constructive activities, and his ability to maintain responsibilities. For comorbidity, the enrollees score is 3, due to recent substance use which has had clearly detrimental effects on the presenting disorder, but has been temporarily arrested through the use of a highly structured or protected setting or through other external means. He has ongoing or episodic substance use occurring; despite adverse consequences, with a significant or potentially significant negative impact on the course of any co-existing psychiatric disorder. For recovery environment level of stress, the enrollees score is 3, due to a significant transition causing disruption in life circumstances; such as job loss. He has easy exposure and access to alcohol and drug use. For recovery environment level of support, the enrollees score is 2, because supportive resources are not abundant, but are capable of and willing to provide significant aid in times of need. For treatment and recovery history, the enrollees score is 3, because previous or current treatment did not achieve complete remission of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 2, because he shows some recognition of his personal role in recovery and accepts some responsibility for it. He demonstrates significant understanding and acceptance of his illness and attempts to understand its effect on function. He has demonstrated willingness to change. He fully participated in groups. The enrollees composite LOCUS score is 18, which correlates with high intensity community-based services. Medical evidence does not support the services at issue in this clinical setting.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.