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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment level of care provided.  Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting.This patient could have received services at a lower level of care. In cases such as this, an evidence based, objective, instrument such as the Level of Care Utilization System (LOCUS) is an accepted, national standard for determining the appropriate level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible.  The patients risk of harm is scored a 3, moderate risk of harm. The patient has no history of prior suicide attempts. The patient did have ongoing chronic suicidal ideation with no plan or intent. The clinical notes state that the risk of self harm was very low. The patients functional status is scored a 3 which correlates to moderate impairment. Due to chronic pain, the patient had to stop working after 32 years.  The patient reported that the patient was not able to function at work due to patients chronic pain and other medical problems. The patients medical, addictive and psychiatric co-morbidity is scored a 3 which correlates to significant co-morbidity. The patient has a co-morbidity of chronic pain and major depressive disorder. The patients recovery environment is scored a 3 which correlates to a moderately stressful environment. Per the documentation, the patient has significant discord with the patients family members. There seems to be significant interpersonal difficulties within the family dynamic. The patients level of support is also a 3 which correlates to limited support. The patient does have some support from family, but as noted above, the patient has significant interpersonal difficulties within the patients family.  The patients treatment history is scored a 3, equivocal response to treatment and recovery. Prior electroconvulsive therapy was helpful, but the patient was unable to tolerate this due to memory problems. According to the records, prior treatment has not achieved a complete remission of symptoms. The patients engagement and recovery status is a 2, positive engagement and recovery. The patient will engage in treatment with providers. The patient is compliant with taking her medication. According to the LOCUS criteria, the patients composite score is 20, which qualifies for a partial hospitalization program (PHP). The patient required treatment for the patients major depressive disorder, but this could have been performed in a less restrictive environment like a PHP level of care. Therefore, the residential treatment level of care provided from dates of dispute were not medically necessary for the treatment of this patients medical condition.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.