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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that The Level of Care Utilization System (LOCUS) criteria is used to objectively determine if the patient meets criteria for length of stay. This is an accepted, national standard for determining the appropriate level of care for adults. The patient had a risk rating of 3 for moderate risk of harm. The patient has been having passive, intermittent suicidal ideation with no plan. The patient excessively uses alcohol, which has resulted in harmful behaviors in the past such as getting a citation for drinking under the influence. His functional status was scored a 3 for moderate impairment. The patient is withdrawn and isolates. He lives alone and has not worked for many years. He has a conflictual relationship with his father, although his father is willing to participate in treatment. The medical/addictive/psychiatric comorbidity is scored a 3 which correlates to significant comorbidity. The patient has a comorbidity of alcohol use disorder and a sex and pornography addiction. His recovery environment is scored a 3 for moderately stressful environment. The patient has a conflictual relationship with his father who the patient feels is demanding and controlling. His level of support is also scored a 3 which correlates to limited support in environment. The patient has interpersonal problems with his father. However, the father is willing to participate in treatment even though from the record, it appears that his father is somewhat ambivalent. His treatment history is scored a 3 for equivocal response to treatment and recovery. The patient was successfully detoxed from alcohol. He has been drinking heavily for the last four to five years and has only been sober for 18 hours during that time.  His engagement and recovery status is scored a 2 which correlates with a positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations. According to the LOCUS criteria, this patients total score is 20. As such, this patient would meet criteria for treatment at a partial hospitalization program (PHP). His comorbidities of pornography and sex addiction did not require the patient to be in a more restrictive environment for the treatment of his alcohol use disorder.  Therefore, residential treatment center services provided 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.