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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center substance abuse level of care. Findings:  The physician reviewer found that in cases such as this an evidence based, objective, instrument such as the Level Of Care Utilization System (LOCUS) for psychiatric and addiction services is indispensable in determining medically necessary 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 2 (low). The patient did not endorse suicidal ideation. Her functional status is scored a 3 (moderate). The patient exhibited fair to poor functional level, intact activities of daily living but a history of issues with school functioning due to substance use. The patients medical, addictive and psychiatric co-morbidity is moderate which correlates with a score of 2 (low). This is due to overall medical stability and no severe psychiatric symptoms. Her recovery environment, level of stress is scored a 2 (low) due to a stable living environment. This patients recovery environment, level of support is noted as supportive, which correlates to a score of 2 (low). Her family is supportive of her recovery. Treatment and recovery history is moderate with a score of 3 (moderate) due to minimal treatment response in the past as well as minimal past history of treatment. Her engagement and recovery status is a 2 (low). This is due to her cooperation in treatment and apparent insight into her need for treatment. This gives the patients presentation a composite score of 16.  This score correlates with a treatment intensity level of three, which correlates to high intensity community based services and not residential treatment services. Utilizing the American Society of Addiction Medicine (ASAM) criteria for level of placement can be applied to this patients presentation to help determine the appropriate level of care.  For dimension 1, acute intoxication and/or withdrawal potential, the patient has a risk rating score of 0 due to lack of withdrawal. For dimension 2, biomedical condition and complications, the patient has a risk rating score of 0-1 due to no active serious medical problems mentioned in the records, the only active issue appears to be some chronic pain. For dimension 3, emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 0-1 indicating some depression and anxiety issues. For dimension 4, readiness to change, the patient has a risk rating of 1 due to motivation to change and investment in treatment. For dimension 5, relapse, continued use, or continued problem potential, the patient has a risk rating of 2 due to minimal sobriety. For dimension 6, recovery/living environment, the patient has a risk rating of 0-1 due to a sober living environment. Overall, the patients presentation suggests risk rating scores between 0 to 2.  This overall risk rating places the patient at a level 2, which correlates to intensive outpatient services.  According to the scores on the two criteria mentioned above, the appropriate level of care for the patient is intensive outpatient care. Therefore, residential treatment center substance abuse level of care were not and are not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are 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.