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

Nature of Statutory Criteria/Case Summary: The patient is a female with diagnoses of severe opioid use disorder, other severe stimulant dependence, bipolar II disorder, and generalized anxiety disorder. A review of the record indicates that the patient had prior treatment that included detoxification and residential treatment center (RTC) level of care treatment in 2012, 2014, and 2016. She reported relapse after these admissions. The patient was admitted on for detoxification with a plan to discharge her to the RTC program. She was medically cleared from detoxification. Physician progress notes indicate that the patient was calm and cooperative with clear and coherent speech. Her mood and her affect were euthymic. Her thoughts were goal oriented. She denied current suicidal and homicidal ideation. She reported previous thoughts of suicide with a plan to overdose in 2015.  Her memory and cognition were intact. She did not express any symptoms of psychosis. Assessment records indicate that the patient endorsed use of one gram of heroin on a daily basis for the last year, and half a gram of methamphetamine for the past day. The assessment indicated that the patient showed signs of willingness to change behaviors that led to her previous relapses. She reported a history of depression, anxiety, and bipolar disorder. The patients score on the Clinical Institute Withdrawal Assessment (CIWA) withdrawal scale was zero. Progress notes indicate that the patient expressed motivation towards maintaining sobriety. Progress notes indicate that the patient presented with a normal affect and was dressed appropriately for the session. Progress notes indicate that the patient was casually dressed, with appropriate grooming and hygiene. She had an appropriate mood with a restricted affect. Her insight and judgment were slightly improved and she was responsive during a therapeutic group discussion, providing insightful feedback when prompted.  She was reported to have made fair progress in her treatment goals. She was noted to remain guarded, but her quality of engagement, insightfulness, and judgment improved when she participated. Progress notes indicate that the patient was actively engaged in the group. She processed being grateful for sobriety and recovery. During RTC treatment, she attended individual and group sessions. Medications during this time included clonidine, quetiapine, and lamotrigine. At issue in this case was whether the RTC services were medically necessary for treatment of the patients medical condition.  The progress notes indicate the patient was admitted after detoxification, or with strong management admission, for approximately one week. Upon presentation to the RTC, the patient was noted to be calm and cooperative, and was free from all withdrawal symptoms. She was noted to be free from psychosis as well as any suicidal or homicidal ideation. She expressed motivation for treatment on numerous occasions. It appears that she had a good support system in place. She did not describe any recent substance use treatment and denied any significant medical problems. She was noted to be somewhat guarded in treatment but actively participated. The records indicate that the patients overall function was good. She was not experiencing behavioral issues or aggression. The American Society of Addiction Medicine (ASAM) criteria for level of placement can be applied to a patients presentation to help determine the appropriate level of care. For dimension one, acute intoxication and/ or withdrawal potential, the patient had a risk rating score of zero due to lack of withdrawal. For dimension two, biomedical condition and complications, the patient had a risk rating score of zero due to no active medical issues. According to the ASAM criteria, both of the dimensions above must be met to qualify for RTC level of care. This was not the case for this patients presentation. The composite score of the patients presentation on the Level of Care Utilization System (LOCUS) on the first disputed day was 15. This score correlates with low intensity community- based services. This scoring was based on the patients low risk of harm (one) due to a lack of current suicidal ideation. The patient has demonstrated moderate functional impairment (three) due to overall fair functional level in treatment, with a history of substance abuse and functional problems when in the community. She has moderate medical, addictive, and psychiatric co-morbidity (two) due to overall medical stability and a history of mood symptoms and substance abuse. The patients recovery environment is mildly stressful due to a stable living environment with family members (two) and a supportive recovery environment (two). The patient has a moderate treatment and recovery history (three) due to current motivation for treatment, but past relapses in the context of no recent treatment. She demonstrated positive engagement and recovery status due to cooperation in treatment (two) per the records. Given these findings, the RTC services were not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested services 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 with subspecialty certification in child and adolescent 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.