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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented to the residential treatment center with a history of substance use. He indicated that he was consuming beer on the weekends only. He reported that he had been sober from marijuana for over two years after completing an intensive outpatient program. Directly prior to his residential treatment center admission, there was no indication that the patient was receiving intensive outpatient or community-based treatment. The patient expressed motivation for treatment. During treatment, he was noted to be cooperative, calm and insightful. The progress notes did not indicate that the patient had psychosis, paranoia or mania symptoms during the residential admission.  The records did not indicate severe psychiatric symptoms requiring intensive psychiatric care. The patient did not express suicidal ideation or severe mood lability during the disputed period. Per the records, he did not have any self-harm behaviors and was medically stable.  The medical record did not indicate the presence of withdrawal symptoms. In terms of risk of harm, the records support a score of 2 due to a lack of current suicidal ideation. With regards to functional status, the records support a score of 3 due to overall fair to good functional level. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no severe psychiatric symptoms. With regards to the level of stress of the recovery environment, the records support a score of 2 due to a stable living environment. In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment. With regards to treatment and recovery history, the records support a score of 3 due to minimal treatment response in past with minimal noted treatment. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and apparent insight into need for treatment. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient treatment. With regards to acute intoxication and/or withdrawal potential, the patient has a risk rating score of 0 due to lack of withdrawal. In terms of biomedical condition and complications, the patient has a risk rating score of 0 to 1 due to no active serious medical problems. With regards to emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 0 to 1 indicating some mild issues that were noted to be under good control with medications. In terms of readiness to change, the patient has a risk rating of 1 due to motivation to change and investment in treatment, With regards to relapse, continued use, or continued problem potential, the patient has a risk rating of 2 due to minimal sobriety. In terms of recovery/living environment, the patient has a risk rating of 0 to 1 due to a sober living environment. Overall, the patients presentation suggests risk rating scores in the range of 0 to 2.  This overall risk rating is consistent with intensive outpatient services. According to the scores on the two instruments noted above, the appropriate level of care for the patient was intensive outpatient care. Therefore, residential treatment center services were not medically necessary for the treatment of this patient. 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.