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

Nature of Statutory Criteria/Case Summary: The patient is a male with adjustment disorder, alcohol use disorder, barbiturate use disorder and benzodiazepine use disorder. The patient also had a diagnosis of small cell lung cancer and was being treated with an agent that required abstinence from alcohol. The patients Clinical Institute Withdrawal Assessment (CIWA) score was two. The patient denied any suicidal or homicidal ideation and had no delusions or hallucinations. The patient did not demonstrate any significant depression or anxiety on symptom scale testing. The patient actively participated in the program. The patient had a prediction of alcohol withdrawal severity score of two, and he rated his cravings as three of 10. At issue in this case is whether RTC services were medically necessary for the treatment of this patients medical condition. Based on review of the records, this patient denied any suicidal or homicidal ideation and did not have any abnormal thoughts or psychosis, including auditory or visual hallucinations. He was cooperative with care and was actively involved in treatment. The patient had stable vital signs and his withdrawal status was stable. He reported difficulty sleeping and took hydroxyzine nightly as needed. The patient had a diagnosis of small cell lung cancer and was receiving treatment. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is helpful in determining the appropriate level of care. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regard to functional status, the records support a score of 2. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with a history of adjustment disorder, polysubstance use disorder, and non-small cell lung cancer. In terms of level of stress of the patients recovery environment, the records support a score of 1 due to a stable living situation. With regard to level of support for the recovery environment, the records support a score of 1 due to family support and availability of treatment resources. With regard to treatment and recovery history, the records support a score of 3 due to recent success at the RTC level of care. In terms of engagement and recovery status, the records support a score of 1 due to cooperation in treatment, insight into his need for treatment and insight into his treatment needs. These scores give the patient a composite score of 11, which correlates with treatment in a community-based outpatient clinic setting. The medical evidence does not demonstrate that the patient required the 24-hour monitoring and medical supervision provided at the RTC level of care. Therefore, the requested RTC services were not medically necessary for the treatment of 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 with subspecialty certification in geriatric 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.