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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for residential treatment center services. The enrollee presented to the residential treatment center (RTC) due to treatment-resistant depression, post-traumatic stress disorder (PTSD), ongoing grief, alcohol/cannabis use disorder and school avoidance. She has a history of self-harming behaviors, ongoing academic/social avoidance, and academic decline; despite engagement in psychotherapy over the past three years. The enrollee became depressed and isolated herself from social interactions after her fathers death, which affected her school attendance. . At the RTC, she participated in art therapy, music therapy, drama therapy, equine therapy, family therapy, group therapy, individual therapy, guided imagery and neurofeedback. During her stay at the RTC, the Lexapro dose was not changed. She demonstrated improvement in her mood and sleep. She was not suicidal or homicidal.  Her initial psychiatric evaluation did not indicate suicidal ideation, homicidal ideation, urges to self-harm or psychotic symptoms. The enrollees history was negative for mania or eating disorders. Admission diagnoses were major depressive disorder (MDD), severe, recurrent without psychotic features; PTSD; alcohol use disorder, moderate, in full remission in a controlled environment; cannabis use disorder, mild in full remission in a controlled environment; and unspecified anxiety disorder. The Level of Care Utilization System (LOCUS), level of care assessment tool used support accurate level of care recommendations was applied in this case. For risk of harm, the enrollees score is 3, due to no active suicidal/homicidal ideation present, but extreme distress and/or a history of suicidal/homicidal behavior exists. For functional status, the enrollees score is 3, due to appearance and hygiene falling below usual standards on a frequent basis. Significant deterioration is present regarding the ability to fulfill responsibilities and obligations to job, school, self, or significant others and these may be avoided or neglected on some occasions. There are chronic and/or variably severe deficits in interpersonal relationships, the ability to engage in socially constructive activities, and the ability to maintain responsibilities. For comorbidity, the enrollees score is 2, due to the existence of medical problems which are not themselves immediately threatening or debilitating and which have no impact on the course of the presenting disorder. Occasional episodes of substance misuse exist, but any recent episodes are self-limited, show no pattern of escalation, and there is no indication that they adversely affect the course of any co-existing psychiatric disorder. For recovery environment level of stress, the enrollees score is 2, due to performance pressure (perceived or actual) in school or employment situations creating discomfort. Potential exposure to alcohol and/or drug use exists. For recovery environment level of support, the enrollees score is 2, due to supportive resources are not abundant, but are capable of and willing to provide significant aid in times of need. Professional supports are available and effective. For treatment and recovery history, the enrollees score is 3, due to previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 3, due to the enrollees significant understanding and acceptance of illness and attempts to understand its affect on function. The enrollee demonstrates willingness to change. The enrollee engages in treatment in a positive manner, is capable of developing trusting relationships, and will use available resources independently when necessary. The enrollees composite LOCUS score is 18, which correlates with high intensity community-based services. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. 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 similar medical condition.