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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for substance related disorders, residential behavioral health level of care, adult detoxification treatment. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested services in this clinical setting. In cases such as this, an evidence based, objective, instrument such as the Level of Care Utilization System (LOCUS) is an accepted, national standard for determining the appropriate level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. With regards to functional status, the records support a score of 3. The patient had moderate impairment in her functional status. She had been withdrawn and ended her relationship with her boyfriend. She has had a significant deterioration to fulfill her responsibilities. The patients risk of harm is scored a 3 which correlates to moderate risk of harm. The patient has no prior history of suicide attempts. She has had past suicidal ideations with no plan or intent. She has a history of excessive alcohol and illicit substance use resulting in harmful behaviors. It does not appear that the patient is aggressive or violent. The patient has significant disturbances in her sleeping and activity level. She recently broke up with her boyfriend which led to a relapse. The patients medical, addictive, and psychiatric comorbidity score is a 3, which correlates to significant comorbidity. The patient has a significant comorbidity of alcohol use disorder, cannabis use disorder, bipolar II, obsessive compulsive disorder (OCD) and attention deficit/hyperactivity disorder (ADHD). It does not appear that the patient has any medical problems, which would require 24 hour observation. The patients recovery environment is a 3, which correlates to moderately stressful environment. Per the documentation, the patient has significant discord with her family members. The patients level of support is a 3, limited support. The patients mother is supportive. She has limited support from others in her environment. Her treatment history is 3, equivocal response to treatment and recovery. The patient was not able to remain at an intensive outpatient level of care due to her inability to remain sober. The patient does attend appointments with her psychiatrist for the management of her bipolar II, OCD, and ADHD and substance problems. Her engagement and recovery status is a 3, limited engagement and recovery. The patient reports that she is motivated to stop using substances. However, the patient has a history of noncompliance, and it appears that she remains ambivalent about her desire to stop using substances. According to the LOCUS criteria, the patients total score is 21. This score would meet criteria for a partial hospitalization program (PHP). The patient requires treatment for her alcohol use disorder, cannabis use disorder, bipolar II, OCD, and ADHD. However, her treatment can be accomplished at a less restrictive environment. As such, substance related disorders, residential behavioral health level of care, adult detoxification treatment are not medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested services 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.