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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services provided for treatment of the enrollees behavioral health condition. Based on the Level of Care Utilization System (LOCUS) criteria,  the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is three (3), moderate risk of harm. The patient has a history of three suicide attempts. She attempted to overdose on beta blockers and slit her wrists. All these attempts were made when the patient was intoxicated. When the patient is sober, she does not have suicidal ideation and loves life and wants to live. As the patient was sober and did not have any suicidal ideation or homicidal ideation. The patients functional status score is three (3), moderate impairment, When the patient has relapsed from sobriety, she is unable to work and has to take time off to recover. The patient is currently employed. The patients recent gains in sobriety have been achieved while participating in treatment in structured settings. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, anxiety, and depression. The patient also has a history of pancreatitis and cirrhosis of her liver. The patient has a history of utilizing alcohol despite negative consequences. The patient has a history of driving under the influence and was recently cited for public intoxication. The patients recovery environment score is two (2), mildly stressful environment. The patient is financially stable and has family and friends that are supportive. The patients level of support score is two (2), supportive environment. The patient has supportive family and friends. The patients treatment history score is three (3), equivocal response to treatment and recovery. Previous treatment had allowed the patient to obtain six months of sobriety. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is cooperative and compliant with treatment. The patient is noted to be highly motivated for sobriety. Based on these criteria, the patient has a total score of 18, which would meet criteria for treatment in a less restrictive environment, such as an intensive outpatient program (IOP). Although the patient continues to need treatment for her alcohol use disorder, the patient improved enough to be treated in a less restrictive environment. Therefore, the PHP services provided was not and is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and are 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.