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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for services provided by Ascend for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria the services at issue were not medically necessary. The patients risk of harm score is three (3), moderate risk of harm. The patient has a history of suicide attempts. She had tried to overdose on 30 tablets of Xanax and has attempted to jump out of a moving vehicle. The patient had intermittent passive suicidal ideation, but recently she has not had active suicidal ideation with a plan. The patients functional status score is three (3), moderate impairment. The patient has conflicted relationships with her family, mainly around drug use. She is unable to hold a job and currently has legal problems. She is unable to go to school due to her substance use, however this is a goal that the patient has. She is able to maintain her hygiene. The patients medical, addictive, and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of cocaine use disorder, cannabis use disorder, alcohol use disorder, anxiolytic use disorder, and stimulant use disorder. The patients substance use has had a clear detrimental effect on her current circumstances. She does not have any serious medical conditions that would require 24 hour monitoring. The patients recovery environment score is three (3), moderately stressful environment. The patient has ongoing interpersonal conflict with her parents over substance use which has led to police being called. The patient also has legal difficulties. The patients level of support score is two (2), supportive environment. The patients parents are supportive of the patient. The patients parents would participate in treatment if asked to do so. The patients treatment history score is three (3), equivocal response to treatment. The patients prior treatments have been modestly successful. The patient has had months of sobriety. She has made a partial recovery which is typically only maintained in a structured setting. The patients engagement and recovery status score is three (3), limited engagement and recovery. The patient is ambivalent about her substance use. She recognizes that it causes problems, but lacks confidence to change. She has a limited ability to accept responsibility for recovery. Based on these criteria, the patients total score is 20, which would meet criteria for a partial hospitalization program. Therefore, services provided by Ascend were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and are 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.