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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment at a dual diagnosis residential treatment program for severe mental illness and chemical dependency. This patient presented to the residential treatment center with a history of substance use. He expressed motivation for his treatment. During his assessment, the patient was noted to be calm and cooperative. He was noted to show insight into his illness. The progress notes did not document psychosis, paranoia or mania symptoms. He did not have depression of a significant nature. The records did not indicate severe psychiatric symptoms that would require intensive psychiatric care. The records did not demonstrate that the patient had tried or failed intensive outpatient treatment for his psychiatric conditions. He did not expression suicidal ideation or severe mood lability. The medical records did not indicate the presence of withdrawal symptoms. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining the necessary level of care for adults. In terms of risk of harm, the records support a score of 2. The records document a lack of current suicidal ideation. With regards to functional status, the records support a score of 3. This patient had overall fair to good functional level. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no severe psychiatric symptoms. With regards to level of stress of the recovery environment, the documentation supports 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. This patient had an overall supportive recovery environment. His spouse is supportive of his recovery and treatment efforts. With regards to treatment and recovery history, the records support a score of 3 due to minimal treatment response in the past with minimal noted treatment. In terms of engagement and recovery status, the records support a score of 2. The patient was cooperative in treatment and had apparent insight into the need for treatment. Thus, the records support a composite score of 16. This score correlates intensive outpatient treatment. The American Society of Addiction Medicine criteria can be applied to help determine the appropriate level of care for this patient. With regards to 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 has a risk rating score of 0 to 1 due to no active serious medical problems noted in the records. With regards to emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 0 to 1, indicating some mild depression issues that were noted to be under good control with antidepressant medications. In terms of readiness to change, the patient has a risk rating of 1 due to motivation to change and investment in treatment. With regards to relapse, continued use, or continued problem potential, the patient has a risk rating of 2 due to minimal sobriety. In terms of 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. According to the scores on the two instruments above, the appropriate level of care for the patient is intensive outpatient care. Therefore, the requested treatment at a dual diagnosis residential treatment program for severe mental illness and chemical dependency is not medically necessary for the treatment of this patient. 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.