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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that The physician reviewer found 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 opiate use. He expressed motivation for his treatment. During treatment, the patient was noted to be cooperative and calm. Per the records, he showed insight into his illness.  The progress notes did not document psychosis, paranoia or mania symptoms during the residential treatment stay. The records did not indicate severe psychiatric symptoms that would require intensive psychiatric care. The records did not indicate that the patient had tried or failed intensive outpatient treatment for his psychiatric conditions. The records did not indicate that the patient had recently engaged in any type of substance use treatment. He did not express suicidal ideation or severe mood lability during the disputed period. The patient did not have any self-harm behaviors and was medically stable. The medical record did not indicate the presence of any withdrawal symptoms.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 2. There was a lack of current suicidal ideation. With regards to functional status, the records support a score of 3. There was overall poor functional level due to opiate use with intact activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2. The records noted overall medical stability and no severe psychiatric symptoms. With regards to level of stress of the recovery environment, the records support a score of 2. This patient has a stable living environment. In terms of level of support of the recovery environment, the records support a score of 2 given an overall supportive recovery environment. In terms of treatment of recovery history, the records support a score of 3. The patient had minimal treatment response in the past. With regards to engagement and recovery status, the records support a score of 2. The records document cooperation in treatment and apparent insight into the need for treatment. Thus, the patient has a composite score of 16.  This score correlates with intensive outpatient treatment.  The American Society of Addiction Medicine criteria can be applied to help determine the appropriate level of care for the patient. With regards to acute intoxication and/or withdrawal potential, the patient had a risk rating score of 0 due to lack of withdrawal. In terms of biomedical condition and complications, the patient had a risk rating score of 0 to 1 due to no active serious medical problems mentioned in the records. With regards to emotional/behavioral or cognitive conditions and complications, the patient had a risk rating score of 0 to 1 indicating some mild depression issues that were noted to be under good control with antidepressant medications. In terms of readiness to change, the patient had 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 had a risk rating of 2 due to minimal sobriety. In terms of recovery/living environment, the patient had 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. All told, residential treatment was 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.