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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. To objectively determine if the patient meets criteria for the services at issue, the Level of Care Utilization System (LOCUS) criteria has been used in this determination. This is an accepted, national standard for determining the appropriate level of care for adults. The patient met the following criteria: With respect to this patients risk of harm, the patients score is a 2, which correlates to low risk. The patient has a history of self-harm including burning herself and cutting herself. This behavior does not appear to be suicidal behavior.  It does not appear that the patient has a history of suicide attempts. The patient did not have any suicidal or homicidal ideation. The patients functional status is scored a 3, moderate impairment. The patient is married. The patient struggles with completing some of the occupational or household responsibilities due to her substance use. With regards to medical/addictive/psychiatric comorbidities, the patients score is a 3. This patient has significant comorbidity. The patient has a history of posttraumatic stress disorder and alcohol use disorder. The patient has a history of Hashimotos disease, but she has a normal thyroid level. The records provided do not demonstrate that she has any medical problems that would require 24 hour supervision. The patients recovery environment is scored a 3. There is discord in her relationships and with her immediate family. The criteria for level of support is scored a 3, which correlates to a limited support in the environment. The patient is married, but it appears the patients spouse is only partially supportive due to interpersonal conflicts. The patients treatment history is scored a 3, which correlates to an equivocal response to treatment and recovery. The patient was receiving outside therapy, which did not help resolve the patients binge drinking and other psychiatric symptoms. The patients engagement and recovery status is scored a 2.  The patient is attentive and engaged during treatment. The patient appears motivated for change and is medication compliant. According to the LOCUS criteria, the patients total composite score is 19, which meets the criteria for intensive outpatient program (IOP) and not residential treatment center. The patient was motivated for treatment. The patient could have attended Alcoholic Anonymous, obtained a sponsor, and started to live in a sober living environment. The patient could have started naltrexone in an IOP program. It does not appear that the patient required medical detoxification as the patient had already been sober for three days prior to admission and had no history of delirium tremens or other complicated withdrawal symptoms. The patient continues to require treatment for the patients posttraumatic stress disorder and alcohol use disorder, but this could have been done in a less restrictive environment. As such, the patient could have been treated in a less restrictive environment.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.