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) level of care services. The enrollee entered a residential treatment center (RTC) for treatment of heroin addiction. The enrollee reported he was mentally exhausted. He started opiates in high school, and heroin at 17-18 years old. Since the start of heroin use, he has accumulated approximately five years of sobriety. He noted his heroin use was due to pain. He was involved in an accident which exacerbated his pre-existing sciatic pain and added significant thoracic and shoulder pain. He had past success with Methadone and Suboxone and remained abstinent when adhering to his medication regimen. This admission is his sixth time in treatment. The discharge recommendation was an intensive outpatient program and sober living. The enrollee reports using two grams of heroin a day for two years. Prior to this, he was sober for a year and a half. The enrollee describes a history of depression and insomnia, but he stated he was never diagnosed. However, he had been prescribed Seroquel and Ativan. He was taking Gabapentin for pain from a motor vehicle accident two years ago. He has no history of suicidal ideation (SI), homicidal ideation (HI), self-harming behaviors, or auditory and visual hallucinations. He denied a history of seizure or blackouts. After admission, he was placed on an opioid withdrawal protocol and was receiving Clonidine, Imodium, Baclofen, Vistaril and Suboxone; when indicated.  The Clinical Opiate Withdrawal Scale (COWS) is used to assess the progress and severity of withdrawal and to guide medication administration. Scores of 5-12 indicate mild withdrawal, 13-24 indicate moderate withdrawal, 25-26 indicate moderately severe withdrawal, and over 36 indicate severe withdrawal. His initial COWS score was 11 and his last was 3. The Level of Care Utilization System (LOCUS), level of care assessment tool, applied in review of this case indicates 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 disturbances in vegetative activities such as sleep, eating habits, activity level, or sexual appetite which do not pose a serious threat to health. He shows significant deterioration in his ability to fulfill responsibilities and obligations to job, school, self, or significant others; which may be avoided or neglected on some occasions. For comorbidity, the enrollees score is 2, due to the existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. He may occasionally experience psychiatric symptoms which are related to stress, medical illness, or substance use, but they 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 a significant transition causing disruption in life circumstances; such as job loss, legal difficulties or change of residence, and easy exposure and access to alcohol and drugs. For recovery environment level of support, the enrollees score is 2, because supportive resources are not abundant, but are capable of and willing to provide significant aid in times of need. For treatment and recovery history, the enrollees score is 3, because previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. At least partial recovery has been maintained for moderate periods of time, but only with strong professional or peer support or in structured settings. For engagement and recovery status, the enrollees score is 2, due to willingness to change. The enrollee shows some recognition of his personal role in recovery and accepts some responsibility for it. The enrollees composite LOCUS score is 17, which correlates with high intensity community-based services. Medical evidence does not support the services at issue in this clinical setting. 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.