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

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with cannabis use disorder. The patient was admitted to a PHP on 8/31/18. On admission, he denied a history of mental health symptoms and any history of suicidal ideation or suicide attempts. His last cannabis use was on 8/10/18. He denied any active medical issues and was noted to be able to complete his activities of daily living. The patient was noted to recognize that he had a substance use problem and expressed motivation for change. On 9/11/18, the patient reported high cravings and a lowering level of anxiety. On 9/12/18, the patients urine drug screen was negative. On 9/14/18, the patient was noted to have had a positive impact on his peers in group therapy. On 9/14/18, no post-acute withdrawal symptoms were noted. He also reported a decrease in cravings, rated as six of 10. The patient endorsed mood swings and denied suicidal ideation. He was noted to have an impaired understanding of relapse prevention. On 9/18/18, the patient was noted to participate in therapy sessions and his mother attended the family program. On 9/21/18, it was noted the patient had strong family support. The patient has requested reimbursement for PHP services that were provided from 9/11/18 through 9/21/18. The Health Plan has denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether PHP services that were provided from 9/11/18 through 9/21/18 were medically necessary for treatment of the patients medical condition. The patient was noted to be cooperative and attentive during group and individual therapy. He reported wanting to remain clean and sober. The patient did not experience any withdrawal symptoms or significant medical issues that impaired his treatment. No aggressive behavior or self-harm was noted during treatment. The patient did not report suicidal or homicidal ideation. He also denied past psychiatric treatment and mental health issues. 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 behavioral health managers and clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The patients risk of harm score is rated as 1, due to a lack of suicidal ideation and no self-harming behaviors. His functional status score was rated as 2, since he was able to perform activities of daily living and did not demonstrate any significant deterioration in function. The patients medical, addictive and psychiatric comorbidity score is rated as 2, due to his overall medical stability and a lack of psychiatric symptoms. The patients recovery environment level of stress score is rated as 3, due to lack of structure in the home environment as the patient was not attending school or working. The recovery environment level of support score is rated as 2, due to family support and availability of treatment resources. The treatment and recovery history score was rated as 3, due to success in the PHP program with a good level of cooperation and maintenance of sobriety. The engagement and recovery status score is 2, due to his cooperation and insight into his need for treatment. The patients composite score of 15 correlates with a treatment intensity level of low intensity community-based services. Therefore, PHP services that were provided from 9/11/18 through 9/21/18 were not medically  necessary for the treatment of this patient.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 a subspecialty certificate 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.