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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with alcohol use disorder and cannabis use disorder in remission. He was admitted to a residential treatment center (RTC) on 8/16/18. On admission, he denied past or present suicidal or homicidal ideation and his last use of alcohol was earlier that day. The patient endorsed a history of depression and denied any medical problems. He indicated past mental health treatment included outpatient therapy in 2016 and 2018. He underwent detoxification from 8/16/18 through 8/20/18. On 9/5/18, the patient reported anxiety about finding employment after discharge. On 9/20/18, the patient reported feeling like he had made progress in treatment. He reported feelings of guilt in regard to causing harm to his marriage. His thoughts were noted to be coherent and his mood was irritable and depressed. On 10/5/18, the patient reported feeling he was in a positive space. His thoughts were coherent and his mood was noted to be irritated and depressed. The patient was discharged to home on 10/15/18. At issue in this case is whether RTC services that were provided from 9/1/18 through 10/15/18 were medically necessary for the treatment of this patients medical condition. The patient was admitted to residential treatment for alcohol use disorder. He did not exhibit withdrawal symptoms during treatment. The patient did not have any plan or intent for self-harm and did not engage in any self-harm behaviors. The patient did not describe any suicidal thoughts or psychosis. The patient expressed motivation, and the need for continued treatment. The American Society of Addiction Medicine (ASAM) criteria is a comprehensive set of guidelines for placement, continued stay and discharge of patients with addiction and co-occurring conditions. For acute intoxication and/or withdrawal potential, the patients score is 0. For biomedical condition and complications, the patients score is 0. 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 behavioral health managers and 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 patients score is 1, due to a lack of past or present suicidal ideation, intent, or plan. For functional status, the patients score is 2, due to a good functional level while in treatment but a history of functional problems including unemployment and substance abuse. For comorbidity, the patients score is 2, due to medical stability and a history of mood symptoms that were under control. For recovery environment, level of stress, the patients score is 2, due to a stable living environment. For recovery environment, level of support, the patients score is 2, due to a supportive recovery environment. For treatment and recovery history the patients score is 3, due to the patients motivation for treatment and willingness to participate in Alcoholics Anonymous. For engagement and recovery status, the patients score is 2, due to the patients participation in treatment. The patients composite LOCUS score is 14, which correlates with a treatment level of low intensity community-based services. The medical evidence does not support the requested services in this clinical setting. Therefore, RTC services that were provided from 9/1/18 through 10/15/18 were not medically necessary for this patient.  Final Result: The reviewer determined that the requested services 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.