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

Nature of Statutory Criteria/Case Summary: An enrollee has requested requested reimbursement for residential treatment care services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation does not support the services at issue in this clinical setting. The records indicated that the patient was cooperative with staff and her activities of daily living appeared intact. The medical records do not support active suicidal ideation or psychosis.  There were no significant or severe behavioral problems noted during this period. The patients intake assessment did not indicate that she had tried or failed any intensive substance abuse treatment. Her overall past behavioral health treatment appeared minimal, according to the records. It did not appear that she was suffering from severe symptoms that would have necessitated 24 hour residential care. The documentation indicated that the patient was functioning well socially. The records did not show that she had any active serious medical problems and there were no symptoms of substance withdrawal noted.  She appeared to be insightful into her need for treatment despite initially not wanting to be at the residential treatment center.In cases such as this, an evidence based, objective, instrument such as the American Society of Addiction Medicine (ASAM) criteria for level of placement can be applied to this patients presentation to help determine the appropriate level of care for this patient.  The patient had a risk rating score of 0 for acute intoxication and/or withdrawal potential due to lack of withdrawal symptoms. For dimension two, which measures the biomedical condition and complications, the patient had a risk rating score of 0. She had no active medical problems. For dimension three, which measures the emotional/behavioral or cognitive conditions and complications, the patient had a risk rating score of 1 indicating mild issues that were stable.  For dimension four, which measures the readiness to change, the patient had a risk rating between 1-2 due to some apparent motivation.  For dimension five, which measures the risk for relapse, continued use, or continued problem potential, the patient had a risk rating between 1-2 due to a minimal period of sobriety.  For dimension six, which measures recovery and living environment, the patient had a risk rating between 0-1 due to a supportive and sober living environment. Overall, the patients presentation suggested risk rating scores within the range of 0 to 2.  According to the ASAM criteria, this patients overall risk rating places the patient at a level 2.1 of care. A level 2.1 rating would indicate a placement at intensive outpatient services (IOP), level of care. The evidence based literature surrounding IOP treatment indicates that, IOPs are an important part of the continuum of care for alcohol and drug use disorders. They are as effective as inpatient treatment for most individuals seeking care. Public and commercial health plans should consider IOP treatment as a covered health benefit. Standardization of the elements included in IOPs may improve their quality and effectiveness, (McCarty, et al). According to the documentation, this patient could have been treated at a less restrictive setting, safely and effectively. In summary, the residential treatment center services were not medically necessary for treatment of this patients medical condition. 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 with sub-specialty certification in child and adolescent 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.