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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment at Aspiro for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that although episodic placement at higher levels of care is often necessary, current psychiatric practice aims to place patients in the least restrictive treatment setting to optimize treatment gains and foster autonomous resilience.  Initially, this patient required intensive specialty care.  However, the record does not support the medical necessity of placement in a residential treatment setting. Developmentally, the patient was intelligent but struggled with inattention, anxiety and the milestone of identity formation.  As such, he may have endured rather chaotic role diffusion manifest by self-defeating cognitive schemas and cyclical maladaptive patterns of behavior. Complicating matters was the contemporaneous diagnoses of bipolar illness and substance use disorder.  However, the onset of symptoms that prompted the acute admission in June 2015 was described as abrupt and occurred in context of substance use. The records show that this patient improved during his psychiatric hospitalization.  He was stabilized on medication.  He was well supported by family with no reported housing issues. He expressed a strong desire to not resume cannabis use. The inpatient team developed a discharge plan to the community, not an intermediate setting.  It does not appear that an independent clinical assessment recommended the level of care or that standard therapies had been exhausted at the time of his admission to the residential program. Indeed, the application of cognitive behavioral therapy or interpersonal social and rhythm therapy are evidence-based interventions for bipolar disorder, while motivation enhancement therapy and 12-step and/or peer-support programing can assist with substance use disorder, all of which can be successfully delivered in the outpatient venue. Moreover, there was no mention of wellness and community based interventions, such as a sober living environment, support groups, exercise, mindfulness and meditation to name a few, which can capitalize on therapeutic gains and meaningfully address at least some impairing symptoms. Although treated with psychotropic medication, there was no report of past trials, besides those from a decade ago, which introduces the possibility that an alternative standard pharmacologic regimen may have been reasonable.  All of this is particularly important in this case as there was no evidence that comprehensive specialty services provided in the outpatient setting would have been inadequate, inappropriate or unsuccessful based on the patients condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. 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.