Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested retrospective authorization and continuation of residential treatment program services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. Standard practice regarding treatment referrals usually progress in a step-wise fashion from less to more restrictive settings.  However, in this case, the initial placement at the residential level of care was medically necessary. In general, the American Psychiatric Association provides the following guidance regarding the level of care decision process:  Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Additionally, the practice guideline jointly authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases:  There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment. In this particular case, the patients polysubstance dependence was complicated by co-occurring chronic pain, rigid and likely self-defeating personality traits, and bipolar disorder, which is a psychiatric condition, associated with poor outcomes and heightened risk for suicide even in the absence of comorbidity. The patients uncontrolled alcoholism and drug use jeopardized his physical and emotional well-being. He had significant medical issues and psychiatric illness.  He had an exacerbation of depressive symptoms, including suicidality, shortly after admission.  His motivation was largely externally-driven upon presentation.  He had few social supports in the community. His marriage was strained, and his spouse had been reluctant to engage in therapy. Perhaps most importantly, the treatment team identified the patient as a high-risk for relapse in the absence of a 24-hour supervised setting and detailed the placement criteria that supported the admission. Based on the substance use history, social environment, chronic pain, psychiatric comorbidity and personality organization, the patient would have promptly relapsed and required re-admission if he was discharged. The services at issue and the setting were safe, appropriate and consistent with good practice. However, considering that the patient was not previously active in chemical dependency services during the episode of illness, there is no evidence to suggest that an initial 30-day course of residential care followed by transition to service delivery in a less restrictive setting, which represents a common progression in community practice, would have been unreasonable or inadequate in addressing the patients behavioral health conditions. Thus, residential treatment program services provided were medically necessary, but not thereafter.Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Specifically, services provided were medically necessary but not thereafter. Therefore, the Health Plans denial should be partially 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.