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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse subacute detoxification received for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the Level of Care Utilization System (LOCUS) criteria is a method used to objectively determine if a patient meets criteria for length of stay. This is an accepted, national standard for determining the appropriate level of care for adults. Around the dates in question the patients risk of harm is scored a 3. The patient has no documentation of a prior suicide attempt. Prior to admission, the patient did have suicidal ideation, which dissipated once care was scheduled. The patient did not have any suicidal ideation.  She has no history of violence towards others. Her functional status is also at 3, moderate impairment. The patient is a homemaker. Per documentation, the patient felt that her substance use was significantly impairing her ability to raise her family and be a good mother. There have also been arguments between herself and her husband. As for her medical, addictive, and psychiatric co-morbidity, it is scored a 3.  The patient has type I diabetes, which requires monitoring. The patient does have a significant co-morbidity of anxiolytic use disorder, depression, and anxiety. The patient has migraines and other medical problems, which exacerbate her mental health problems. The patients recovery environment is scored a 3. The patient lives with her husband and her two children with ages 10 and 15. From the documentation provided, there is some discord in the marital relationship. Her level of support is assessed at 3. The patient reported that her husband is not supportive, and he does not believe that she has problems with overuse of her medications. The patient does have support from other family members that may be capable of providing support if needed. Her treatment history is scored a 3. The patient has had no prior treatments for her substance use.  Her engagement and recovery status is scored a 2. The patient is friendly and cooperative with staff. She is accepting of treatment and is willing to engage in psychotherapy and psychopharmacology. According to the LOCUS criteria, her total score is 20. The patient was assessed using the Clinical Institute Withdrawal tool and according to this assessment tool, the patient was not undergoing severe withdrawals. Based on the LOCUS criteria, this patient continued to require treatment for her anxiolytic use disorder, depression, and anxiety. However, her treatment could have been provided in a less restrictive environment like a partial hospitalization program (PHP). 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.