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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient substance abuse rehabilitation for treatment of his behavioral health condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. The patient could have received services at a lower level of care. In cases such as this, an evidence based, objective, instrument such as the Level Of Care Utilization System (LOCUS) is an accepted, national standard for determining the appropriate level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible.  According to the LOCUS criteria, the patients risk of harm is assessed with a score of 2, which is a low risk of harm. The patient did not have any suicidal or homicidal ideation. The patient had excessively used alcohol for many years, but he had no legal problems due to his substance use. His functional status is also a 2, which is mild impairment. The patient has been able to fulfill his work responsibilities. He is actively engaged with the treatment program. His medical/addictive/psychiatric co-morbidity is a 3 which is significant co-morbidity given his severe alcohol use disorder and a seizure disorder. The patients recovery environment is scored as a 3 with moderately stressful environment. The records show that his spouse is supportive. There is some concern related to a decline in his health over his drinking. His level of support is a 2 which correlates to a supportive environment. The patients spouse is supportive of the patient. The patients treatment history is a 2, which is a significant response to treatment and recovery. The patient has had no prior treatment for his alcohol use disorder. However, the patient is positive and participating in treatment. His engagement and recovery status is a 2 which corresponds to positive engagement and recovery. The patient reports that he is motivated for recovery and treatment. He is participating in the milieu, groups, and individual therapy. He is working with his doctor regarding medications for craving management. According to the LOCUS criteria, he patients total composite score is 16. The composite score of 16 indicates that he requires treatment for his alcohol use disorder but he could be treated as an outpatient. Therefore, the patient could have been treated in a less restrictive environment. All told, the inpatient substance abuse rehabilitation was not medically necessary for 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.