Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential substance related disorder treatment or the treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that This patient presented with a history of not showing up to partial hospitalization program level of care due to using substances. Prior to receiving the disputed services, the patient received an inpatient detoxification treatment course. During his stay, the patient showed appropriate grooming, and his activities of daily living appeared intact. The patient showed motivation to change his behaviors, and he openly engaged in therapy. The progress notes from the disputed period indicate that the patient was cooperative in treatment and open to therapy. He did not express suicidal ideation or severe mood lability during the disputed period. The patient was medically stable, and the medical records did not indicate the presence of any withdrawal symptoms. In cases such as this, an evidence-based, objective, instrument such as the Level of Care Utilization System (LOCUS) is indispensable in determining the necessary level of care for adults.  Using LOCUS, in terms of risk of harm, the records support a score of 2.  The records do not indicate current suicidal ideation. With regards to functional status, the records support a score of 3 due to overall fair functional level and intact activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 3.   With regards to level of stress of the recovery environment, the records support a score of 2. The patient had a stable living environment.  In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment with his family.  With regards to treatment and recovery history, the records support a score of 3. The patient had minimal treatment response in past but also a minimal past history of treatment. In terms of engagement and recovery status, the records support a score of 2. The patient was cooperative in treatment and had apparent insight into his need for treatment. Thus, he has a composite score of 17.  This score correlates with intensive outpatient treatment. The American Society of Addiction Medicine criteria can also be applied in this case to help determine the appropriate level of care for the patient. With regards to acute intoxication and/or withdrawal potential, the patient had a risk rating score of 0 due to lack of withdrawal. In terms of biomedical condition and complications, the patient had a risk rating score of 1 to 2 due to no active serious medical problems.  With regards to emotional/behavioral or cognitive conditions and complications, the patient had a risk rating score of 1 indicating mild mood issues that are stable. In terms of readiness to change, the patient had a risk rating of 1 to 2 due to motivation to change and investment in treatment.  With regards to relapse, continued use, or continued problem potential, the patient had a risk rating of 2 due to minimal sobriety. In terms of recovery/living environment, the patient had a risk rating of 0 to 1 due to a sober living environment. Overall, the patients presentation suggests risk rating scores in the range of 0 to 2.  This overall risk rating is also consistent with intensive outpatient services. Therefore, residential substance related disorder treatment provided was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the 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 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.