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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented to the residential treatment center after undergoing withdrawal management in a detoxification setting.  Her withdrawal from alcohol was complete at the time of her admission to the residential treatment center. During her stay, the patient showed appropriate grooming, and her activities of daily living appeared intact. The patient showed motivation to change her behaviors, and she openly engaged in therapy. The progress notes from the disputed period indicate that the patient was cooperative in treatment and open to therapy. The patient did not express suicidal ideation or severe mood lability during the disputed period. She did not have any self-harm behaviors and was medically stable. The medical records did not indicate the presence of any withdrawal symptoms. In cases such as this, an evidence-based, objective, instrument such as the Level of Care Utilization System (LOCUS) is indispensable in determining necessary level of care for adults. The LOCUS was utilized to determine the appropriate level of care in this patients case. In terms of risk of harm, the records support a score of 2. The records do not document current suicidal ideation. With regards to functional status, the records support a score of 3. The records support an overall fair functional level, intact activities of daily living, but a history of issues with daily functioning due to alcohol use. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 3. The records demonstrate overall medical stability, but anxiety and depression symptoms. With regards to the recovery environment level of stress, the records support a score of 2. The patient had a stable living environment. In terms of recovery environment level of support, the records support a score of 2. This patient had an overall supportive recovery environment. With regards to treatment and recovery history, the records support a score of 3. This is due to minimal treatment response in past, but also minimal past history of treatment. In terms of engagement and recovery status, the records support a score of 2. The records noted cooperation in treatment and apparent insight into need for treatment. Thus, the patient has a composite score of 17. This score correlates with intensive outpatient treatment. The American Society of Addiction Medicine criteria for level of placement can be applied to the patients presentation to help determine the appropriate level of care. 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 1 to 2 due to no active serious medical problems. In terms of emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 2 indicating mood and anxiety issues that are stable. With regards to readiness to change, the patient has a risk rating of 1 due to motivation to change and investment in treatment. In terms of 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. 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.