Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: The submitted documentation does not support the services at issue in this clinical setting. The notes demonstrate that the patient was cooperative with treatment.  The patient was diagnosed with anxiety and some depression during the patients stay. The patient was known to have an anxiety in relation to the patients fears about maintaining sobriety. The patient reported that treatment was beneficial. The majority of the patients irritable mood, anxiety and agitation appeared to be due to his relationship with his family. The patient was cooperative in family sessions as well as his family.  The patients family was noted to regularly engage in treatment requests. The patient was described as not comfortable with peers but there was no documentation that indicated the patient had aggression towards peers or staff during his stay. The patient reported continued substance cravings during his stay. The patient was not displaying any signs of self harm behavior, or aggression towards others according to the documentation provided. He had no active serious medical problems and no symptoms of substance withdrawal.   The American Society of Addiction Medicine (ASAM) criteria for level of placement are appropriate to apply to the patients presentation to help determine the appropriate level of care. For dimension 1, acute intoxication and/ or withdrawal potential, the patient had a risk rating score of 0, due to lack of withdrawal symptoms. For dimension 2, biomedical condition and complications, the patient had a risk rating score of 0, due to no serious medical condition. For dimension 3, which correlates to emotional/behavioral or cognitive conditions and complications, the patient had a risk rating score between 1-2, indicating mild to moderate issues that are stable. For dimension 4, readiness to change, the patient had a risk rating between 0-1, due to some motivation for change. For dimension 5, which correlates to risk for relapse, continued use, or continued problem potential, the patient had a risk rating of 2 due to a minimal recent period of sobriety. For dimension 6, recovery/living environment, the patient had a risk rating of 1, due to a supportive and sober living environment with family despite some relationship problems. Overall, the patients presentation suggests a risk rating score within the range between 0 to 2.  This composite risk rating places the patient at a level 2.1 of care according to the ASAM criteria. Level 2.1 correlates to intensive outpatient services (IOP), which is approximately nine or more hours of service per week. The evidence based literature surrounding IOP treatment indicates that IOP level of care is an important part of the continuum of care for alcohol and drug use disorders. The literature indicates that IOP level of care is as effective as inpatient treatment for most individuals seeking care.  The standard of care for minors suggest that children/youth should be treated in the setting that is least restrictive and disruptive to their lives. As such, the literature indicates that inpatient or residential treatment should only be medically indicated in emergencies or for minors who have not responded to efforts at outpatient treatment.  In this patients case, the progress notes provided do not reflect a need for RTC level of care. Instead, this patient could have benefitted from continued substance use treatment on an outpatient basis. The evidence based literature for adolescent cannabis treatment indicates that cognitive behavioral therapy performed on an outpatient basis is effective for the treatment of this disorder. The records do not indicate that this patient has attempted outpatient cognitive behavioral therapy. According to the ASAM criteria, the patient could have been treated in a less restrictive setting safely and effectively.  The records do not demonstrate that this patients symptoms necessitated 24 hour residential care. In summary, RTC services were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that 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 with sub-specialty certification in child and adolescent 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.