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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential substance abuse treatment for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found the patient presented to the residential treatment center with a history of alcohol use disorder. He expressed motivation for his treatment and presented on a voluntary basis. During treatment, he was noted to be cooperative and calm, and breathalyzer evaluations indicated that he did not relapse during treatment. He was also noted to show insight into his illness. The progress notes did not document psychosis, paranoia or mania symptoms during the residential treatment stay. He had depression and anxiety that were both noted to be mild. The records did not indicate severe symptoms that would require intensive psychiatric care. The records did not indicate that the patient had tried or failed intensive outpatient treatment for his psychiatric conditions. He did not express suicidal ideation or severe mood lability during the disputed period. The patient did not have self-harm behaviors and was medically stable. The medical records did not indicate the presence of withdrawal symptoms, as he had completed a detoxification stay prior to his residential treatment center admission. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is an evidence-based, objective, instrument which is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 2. There was a lack of current suicidal ideation. With regards to functional status, the records support a score of 3. There was overall poor functional level due to alcohol use, with intact activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2. The records support overall medical stability and no severe psychiatric symptoms. With regards to level of stress of the recovery environment, the records support a score of 2. In terms of level of support of the recovery environment, the records support a score of 2. The patient had an overall supportive recovery environment with family. With regards to treatment and recovery history, the records support a score of 3. The patient had minimal treatment response in the past. In terms of engagement and recovery status, the records support a score of 2. The patient was cooperative in treatment and demonstrated apparent insight into the need for treatment. Thus, the patient had a composite score of 16. This score correlates with intensive outpatient treatment. The American Society of Addiction Medicine criteria for level of placement can also help determine the appropriate level of care for the patient. With regards to acute intoxication and/or withdrawal potential, the patient had a risk rating score of 0 due to lack of withdrawal. In terms of biomedical condition and complications, the patient had a risk rating score of 0 to 1 due to no active serious medical problems mentioned in the records. With regards to emotional/behavioral or cognitive conditions and complications, the patient had a risk rating score of 0 to 1, as he had some mild depression and anxiety issues that were noted to be under good control with antidepressant medications. In terms of readiness to change, the patient had a risk rating of 1 due to motivation to change and investment in treatment. With regards to relapse, continued use, or continued problem potential, the patient had a risk rating of 2 due to minimal sobriety. In terms of recovery/living environment, the patient had a risk rating of 0 to 1. Overall, the patients presentation suggests risk rating scores in the range of 0 to 2. This overall risk rating is consistent with intensive outpatient services. The current medical evidence does not support the services at issue in this clinical setting. Therefore, residential substance abuse treatment was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.