Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A old male enrollee has requested reimbursement for residential treatment center services provided for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that Modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains. However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addiction and comorbid mental illness. In this case, the patient had a serious addiction to alcohol which contributed to interpersonal discord, anxiety, depression and fear that he may inadvertently harm someone while inebriated. He reported an early age of first use, which is associated with more severe cases of alcoholism. He drank daily, often to the point of blacking out. He had strained relationships due to his drinking. Upon presentation, his blood alcohol level was four times the legal limit, and he was hypertensive and tachycardic. Further, he had multiple co-occurring psychiatric disorders and a self-critical personality. Thus, the residential placement was indicated. The patient had not consolidated the treatment gains necessary to succeed in a less restrictive treatment setting . He was anxious and still being treated for withdrawal with a phenobarbital taper, while a reasonable aftercare plan was not in place. Based on the longitudinal history and medical documentation, the patient would have likely relapsed and required re-admission in the absence of the disputed residential programming. Both the services and setting were safe, appropriate and consistent with good practice while the duration of treatment. Additionally, the services provided were for active treatment delivered in accordance with a treatment plan, and reasonably expected to bolster his resilience, improve his condition and prevent a more serious episode of illness. Considering the clinical presentation and peer-reviewed literature, the residential treatment center services provided were medically necessary for treatment of the patients behavioral health condition.  In regards to the partial hospitalization program services, specialty aftercare in a less restrictive setting was indicated. However, the patient had not been active in chemical dependency treatment during the episode of illness. He had a supportive family, he was stable on psychotropic medication, and he was motivated for treatment. In sum, the record does not reflect that comprehensive, evidence-based services provided in an outpatient program would have been inadequate. The severity of the patients alcohol use disorder, coupled with the patients positive social supports, therapeutic momentum and motivation, warranted step-down for treatment at a lower level of care such as intensive outpatient treatment . As such, the partial hospitalization program services provided were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. 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.