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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center level of care. Findings:  The physician reviewer found that cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining the necessary level of care for adults. The Level of Care Utilization System identifies six evaluation parameters for assessment of service needs. Taking the above into account, the patient may be assigned a risk of harm rating of 4, which corresponds with serious risk of harm. The patient has had two suicide attempts in the past year and three suicide attempts in the past three years. He is described as still expressing that his next attempt will be successful. The patient has used various means such as attempted hanging, overdose, and pills. He has made some of these attempts while under the influence of Xanax or alcohol. Reflects current suicidal ideation with an expressed intention and/or past history of carrying out such behavior. The patient may be assigned a functional status rating of 4 to reflect serious functional impairment. This scoring reflects that he is reported to be estranged from his siblings and his daughter. He recently had a domestic disturbance and there is a restraining order against him. He lost his business and is no longer working, as he lost his business license. This reflects that the patient has had a serious decrease in the quality of his interpersonal relationships as well as an inability to perform close to usual standards in work, parenting or other obligations. In assessing the patients medical, addictive, and psychiatric co-morbidity, the patient may be assigned a comorbidity rating of 3, as the patient has significant co-morbidity. This is because the patient has been drinking a 12 pack of beer on a daily basis and misusing prescription Xanax. He also uses marijuana on a regular basis. He was under the influence when he made his last suicide attempt. Substance abuse is therefore present, with significant adverse effect on the patients functioning and his presenting condition. The patients recovery environment may be assigned a level of stress rating of 4, to correspond with a highly stressful environment. The patient has been evicted from his housing, he has a restraining order filed against him following a domestic disturbance, and he has no source of income and lost his business. The patient has therefore had a serious disruption of family milieu and severe disruption in his life circumstances, such as losing housing. The patients recovery environment may be assigned a level of support rating of 3, to correspond with limited support in his environment. The patient has an outpatient psychiatrist and a therapist, however he has not consistently utilized these resources and he has very limited natural supports in the community. Under these circumstance, a few supportive resources exist in the patients current environment who may be capable of providing some help if needed. With regard to treatment and recovery history, the patient may be assigned a rating of 3 to reflect moderate or equivocal response to treatment and recovery management. The patient was only recently engaged in treatment and has not yet had improvement in his level of depression. He has had difficulty with following up at a lower level of care. The patients previous or current treatment has not achieved optimal control of his symptoms. The patient may also be assigned an engagement and recovery status rating of 3, which corresponds with incomplete engagement. The patient was noted to be isolative and wary of others in treatment groups. He was noted to have poor insight into the role of alcohol and cannabis in his mood disorder. The patient therefore relates to treatment with some difficulty, establishes few trusting relationships, and has hesitation in acceptance of illness. When added together, these ratings produce a composite score of 24, which indicates that the patient qualifies for a Level 5: Medically Monitored Residential Services level of care. Accordingly, the requested Residential Treatment Center level of care was, and is, medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.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.