Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with bipolar disorder, cannabis use disorder, cocaine use disorder, and sedative, hypnotic, or anxiolytic dependence. The patient was admitted to a residential treatment center (RTC) for one month. A few months later, the patient was placed on an involuntary hold due to symptoms of bipolar depression and suicidal ideation and the patient was treated with Seroquel and Abilify. Three days later, the patient was discharged from the hospital and admitted to a RTC. The records document the patient required stabilization for depression, cravings, and high risk of relapse. The patients vital signs were stable and did not indicate physiological withdrawal symptoms. The patient reported that they could not remain sober without assistance. The patient reported anxiety and depression levels rated as six out of 10. The patient also reported cravings at a level of seven out of 10. The patient lacked coping skills, had poor impulse control, was unable to form relationships, and had low self-esteem. The patient was noted to be at high risk for relapse given the cravings, history of withdrawal and continued drug use despite negative consequences. The patient was intermittently described as withdrawn and anxious throughout the RTC stay. Later, the patient was noted to have increased energy and was participating in the program with a strong interest in recovery related topics. The patient was noted to have minimal insight into addiction, recovery, and relapse prevention. The next day, the patient was noted to be withdrawn, isolating, and had decreased interaction. Plans after discharge included outpatient level of care and resuming alcoholics anonymous meetings. The patient has requested reimbursement for RTC services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether RTC services were medically necessary for the treatment of this patients medical condition. According to the American Society of Addition Medicine (ASAM), RTCs are intended to provide 24-hour care with trained counselors to stabilize multidimensional imminent danger and prepare for outpatient treatment. In this case, the patient was observed to have significant cravings and noted to have a high risk of relapse. Furthermore, the patient stated that they could not stay sober in an outpatient setting. The patient had many risk factors for relapse, including substance dependence, continuing to use despite negative consequences and financial instability. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by behavioral health managers and clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. With regard to risk of harm, the patient was at significant potential risk given recent suicidality and polysubstance dependence, indicating a score of 3. In functional status, the patient had moderate impairment for the inability to work and need to live in a sober house, indicating a score of 3. In comorbidity, the patient had comorbid bipolar disorder with recent involuntary inpatient admission, indicating a score of 4. The recovery environment level of stress was moderate given the lack of finances, indicating a score of 3. In recovery environment level of support, the patient had some family support, indicating a score of 3. In resiliency and treatment history, the patient had previous residential treatment and has not achieved complete remission, indicating a score of 3. In acceptance and engagement, there was poor insight into their addiction, indicating a score of 3. In acceptance and engagement, the patient had limited engagement, indicating a score of 3. The patient has a composite score of 25, which indicated that RTC was the appropriate level of care for this patient. Thus, the RTC services provided were medically necessary for treatment of this patients behavioral health issues.  Final Result: The reviewer determined that the requested services were 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.