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 (RTC) rehabilitation services. The patient has opioid use disorder, severe; alcohol use disorder, severe; and sedative use disorder, severe. He reports addictions to oxycodone, alcohol, and Ambien. He began using alcohol at an early age. Years later he was consuming alcohol nightly. He later reduced his consumption to a few drinks on the weekends. He eventually returned to drinking every night. He became addicted to narcotic pain medications after a surgery. He began taking Ambien every night. Per patient report, by the time he entered the residential treatment center (RTC) level of care, he was combining pain medication with alcohol and Ambien. This was his first attempt at treatment. His initial assessment noted he was having signs of withdrawal. He was experiencing headaches, tremors, anxiety and itching. He did not have auditory or visual hallucinations. He did not have any suicidal ideation (SI) or homicidal ideation (HI). While in treatment, he attended all groups, classes and lectures, including morning therapeutic group, gender-specific and mixed gender process groups, relapse prevention groups, cognitive behavioral therapy groups, 12-step informational groups, stress reduction groups and weekly individual sessions with his counselor. The patient attended Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) recovery meetings three times per week. The focus of treatment was addiction management, relapse prevention, self-care, mental health, and coping with stress. Upon admission, the patient was placed on the clinical opiate withdrawal scale (COWS) and the clinical institute withdrawal assessment of alcohol scale (CIWA). His outpatient medications of Prozac and Ambien were continued. His initial COWS scores showed he was in mild withdrawal. His initial CIWA scores showed mild to moderate withdrawal. After ten days, his scores had dropped below the withdrawal threshold. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations and was applied in this case. For risk of harm, the patients score is 2, due to substance use without significant episodes of potentially harmful behaviors. For functional status, the patients score is 2, due to the patient developing minor but consistent difficulties in social role functioning and meeting obligations, such as difficulty fulfilling parental responsibilities or performing at an expected level in work or school, but maintaining the ability to continue in those roles. The patient is demonstrating significant improvement in function following a period of deterioration. For comorbidity, the patients 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. The patient may occasionally experience psychiatric symptoms related to stress, medical illness, or substance use, but they are transient and have no discernable impact on the co-existing substance use disorder. For recovery environment level of stress, the patients score is 3, due to a significant transition causing disruption in life circumstances such as job loss, legal difficulties or change of residence. There is easy exposure and access to alcohol and drug use. For recovery environment level of support, the patients 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 effectively engaged. For treatment and recovery history, the patients score is 1, due to no prior experience with treatment or recovery. For engagement and recovery status, the patients score is 2, due to significant understanding and acceptance of illness and attempts to understand its affect on function. The patient demonstrates willingness to change. The patients composite LOCUS score is 14, which correlates with low 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 services were 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.