Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for transitional living services that include: (24-hour care and supervision, medication management, case management, crisis management, social rehabilitation, independent living skills, physical fitness, family support, monitoring program, companion services, vocational and educational assistance, peer monitoring, activities of daily living, nutrition focused and transportation) for treatment of the enrollees schizophrenia. Findings:  The physician reviewer found that based on the documentation provided for review, transitional living services provided were and are medically necessary for treatment of the patients medical condition. The U.S. medico-social policy of shifting patients from long-term treatment facilities to community-based services was given the term of deinstitutionalization. The well-intended guiding principle of deinstitutionalization was that severe mental illness should be treated in the least restrictive setting. Transitional housing refers to a model in which patients can shift between different levels of supervised housing based on their clinical needs. The paradigm is a critical element of contemporary treatment for those suffering from severe mental illness, such as schizophrenia. The patient in this case is significantly impaired due to his diagnosis of schizophrenia. The patient struggles in all functional domains due to disordered thinking. The patient has a court-appointed conservator. The patient is prescribed clozapine, a medication typically reserved for the most refractory cases of psychotic illness. The patient has a history of nonadherence, overdosing and multiple hospitalizations. The patient appears to be engaged in active treatment and showing modest improvement. However, there is evidence of a lingering formidable illness burden and need for ongoing comprehensive treatment. Further, the housing services are recommended by the treating psychiatrist. Considering the case in its entirety, relevant literature, and current treatment standards, the services in dispute are safe, appropriate, and consistent with good medical practice and reasonably expected to prevent a more serious episode of illness. Thus, the transitional living services that include: (24-hour care and supervision, medication management, case management, crisis management, social rehabilitation, independent living skills, physical fitness, family support, monitoring program, companion services, vocational and educational assistance, peer monitoring, activities of daily living, nutrition focused and transportation) provided were and are medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.