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 conditions. Findings:  The physician reviewer found that this patient presented with a short history of depressive symptoms that started three to four months prior to his admission. The patients treatment history was limited and included approximately one month of psychiatric medication management and some treatment for his substance use approximately four years prior. The patient presented with paranoid ideas, and these paranoid ideas continued throughout his stay at the residential treatment center. During his stay, he showed appropriate grooming, and his activities of daily living appeared intact. The patient showed motivation to change his behaviors, and he openly engaged in therapy.  The progress notes from the disputed period indicate that he was cooperative in treatment and open to therapy. The patient did not express suicidal ideation or severe mood lability during the disputed period.  He did not have any self-harm behaviors and was medically stable. The medical records did not indicate the presence of any withdrawal symptoms. In cases such as this, an evidence-based, objective, instrument such as the Level of Care Utilization System (LOCUS) is appropriate in determining the necessary level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. Based on LOCUS, this patient had a low risk of harm, scored as a 2. The records noted a lack of current suicidal ideation. The documentation noted moderate functional status, and intact activities of daily living. Thus, he scored as 3 in terms of functional status. In terms of medical, addictive and psychiatry comorbidity, this was minor in this patients case, and he scored as 2.  The records noted overall medical stability and some alcohol use.  The level of stress of his recovery environment was mild, as he had a stable living environment.  Thus, he scored as 2. The records noted an overall supportive recovery environment, scored as 2.  Regarding treatment and recovery history, the patient had minimal treatment response in the past, but also minimal past history of treatment. Thus, his score was 3 in this category. The patients engagement and recovery status was positive due to good cooperation in treatment and apparent insight into his need for treatment, resulting in a score of 2.  This gives him a composite score of 16.  This score correlates with a treatment intensity level of low intensity community-based services. Overall, the patients symptoms were mild on presentation. The patient was cooperative in treatment and could have safely been treated in a less restrictive setting.  The American Society of Addiction Medicine criteria for level of placement can also be applied to this patients presentation to help determine the appropriate level of care.  Although the patient did not present primarily for substance use treatment, this was a concern of his, as well as the treatment team.  Regarding acute intoxication and/or withdrawal potential, the patient has a risk rating score of 0 due to lack of withdrawal. In terms of biomedical condition and complications, the patient a risk rating score of 0 due to no active serious medical problems.  Regarding emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 1, indicating mild mood and paranoia issues that are stable. In terms of readiness to change, the patient had a risk rating of 0-1 due to motivation to change and investment in treatment.  Regarding relapse, continued use, or continued problem potential, the patient had a risk rating of 1 due to some sobriety.  In terms of recovery/living environment, the patient had a risk rating of 1 due to a sober living environment.  Overall, the patients presentation suggests risk rating scores in the range of 0 to 1.  This overall risk rating supports outpatient services. Final Result: The reviewers 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 Physician 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.