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. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented to the residential treatment center with a history of substance use that had apparently worsened over the two to three months prior to his admission. On admission assessment, the patient denied psychiatric symptom concerns. During treatment, he was noted to be cooperative with staff. The progress notes did not reflect serious psychiatric symptoms during treatment. On a few occasions, he was noted to have some difficulty focusing, but it did not appear to impede his progress in treatment. The progress notes did not reflect oppositional or defiant behavior with treatment center staff. The records did not indicate that the patient had psychosis, paranoia or mania symptoms during the residential treatment stay. He showed motivation to change his behaviors, and he openly engaged in therapy. The progress notes from the disputed period indicate that the patient was cooperative in treatment and open to therapy. The patient was noted to be working on his GED during treatment. He did not express suicidal ideation or severe mood lability during the disputed period. The patient did not have any self-harm behaviors and was medically stable. The medical records did not indicate the presence of withdrawal symptoms. The American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 2. There was a lack of current suicidal ideation. With regards to functional status, the records support a score of 3. The patient had overall fair to poor functional level. There were intact activities of daily living, but a history of issues with daily functioning due to theft and substance abuse. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2. The documentation noted overall medical stability and no severe psychiatric symptoms. With regards to level of stress of the recovery environment, the records support a score of 2. The patient had a stable living environment. In terms of level of support of the recovery environment, the records support a score of 2. The patient had an overall supportive recovery environment with his family. With regards to treatment and recovery history, the records support a score of 3. The patient had minimal treatment response in the past, but also a minimal past history of treatment. In terms of engagement and recovery status, the records support a score of 2. The patient was cooperative in treatment and demonstrated apparent insight into the need for treatment. Thus, he has a composite score of 16. This score correlates with intensive outpatient treatment. The American Society of Addiction Medicine (ASAM) criteria for level of placement can be applied to patients presentation to help determine the appropriate level of care.  With regards to acute intoxication and/or withdrawal potential, the patient had a risk rating score of 0 due to lack of withdrawal. In terms of biomedical condition and complications, the patient had a risk rating score of 0 due to no active serious medical problems. With regards to emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 0 to 1, indicating some attention difficulties that are overall stable. In terms of readiness to change, the patient had a risk rating score of 1 due to motivation to change and investment in treatment. In terms of relapse, continued use, or continued problem potential, the patient a risk rating of 2 due to minimal sobriety. With regards to recovery/living environment, the patient has a risk rating of 0 to 1 due to a sober living environment. Overall, the patients presentation suggests risk rating scores in the range of 0 to 2. This overall risk rating is consistent with intensive outpatient services. The current medical evidence does not support the services at issue in this patients case. All told, residential treatment center services provided during the dates of service in question were not medically necessary for the treatment of this patient. 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.