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. The enrollee has a long history of alcoholism and cocaine use. The enrollees alcohol consumption increased over the last six months due to increasing depression and anxiety. The enrollee completed detoxification and entered a residential treatment center level of care. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm, the enrollees score is 2, due to substance use without significant episodes of potentially harmful behaviors. For functional status, the enrollees score is 3, due to significant deterioration in the ability to fulfill responsibilities and obligations to job, school, self, or significant others, and these may be avoided or neglected on some occasions. The enrollee demonstrates chronic and/or variably severe deficits in interpersonal relationships and the ability to engage in socially constructive activities. For comorbidity, the enrollees score is 2, due to the enrollee may occasionally experience psychiatric symptoms which are related to stress, medical illness, or substance use, but which are transient and have no discernable impact on the 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 drug use. For recovery environment level of support, the enrollees score is 3, due the 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. There is limited constructive engagement with any professional sources of support which are available. For treatment and recovery history, the enrollees score is 3, due to previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 3, due to some variability or equivocation in acceptance or understanding of illness and disability is present. The enrollee relates to treatment with some difficulty and establishes few, if any, trusting relationships. The enrollees composite LOCUS score is 19, which correlates with Level III, High Intensity Community Based services; however, because the sum of IV A and IV B is more than 5, the recommended level of care could also be considered at a Level IV, Medically Monitored Non-Residential Services.Final Result: The reviewer determined that the requested services were 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.