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 for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) criteria to determine the appropriate levels of care the patient scored 19 meeting criteria for an intensive outpatient program. The patients risk of harm score is three (3), moderate risk of harm. The patient had an overdose. The documentation reports that the patient did not know if the overdose was a suicide attempt or not. She had no reported prior suicide attempts. The patient denied any suicidal ideation. The documentation reported that the patients provider felt that the patient was a low acute suicide risk. The patients functional status is three (3), moderate impairment. The patient had some difficulty showering, but would do so if prompted. Her hygiene and appearance would fall below usual standards on a frequent basis. She had difficulty engaging and maintaining interpersonal relationships. Recent gains have been achieved while participating in a structured setting. Her medical/addictive/psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a diagnosis of obesity which may adversely affect the course of her presenting disorder. She has borderline traits and major depressive disorder. She has a history of alcohol abuse and illicit drug experimentation, but the documentation reports that the patient is currently sober from substances. The patients recovery environment score is two (2), mildly stressful environment. The patient is married. She is close to her daughter. The patients level of support score is two (2), supportive environment. The patient has her daughter and husband as a support system. These supportive resources are capable and willing to provide support in times of need. The patients treatment history score is three (3), moderate response to treatment. The patient had a moderate response to treatment. She was previously treated in intensive outpatient programs. The patients engagement and recovery status score is three (3), limited engagement and recovery. The patient appears to have difficulties engaging in treatments at times. She had hesitation and ambiguity to engage in treatment when first admitted. However, the patient was willing and engaging in treatment. Moreover, the patient did not have any suicidal or homicidal ideation. The patient did not have any psychosis, mania, delusions, hallucinations, or agitation. The patient was calm, cooperative, and engaged in treatment. The patient was sleeping well and medically stable. The patient continued to require treatment for her depression and borderline traits, but this could have been done in a less restrictive 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.