Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The enrollee presented to the residential treatment center with a history of substance use. The enrollee expressed motivation for treatment. During treatment, the patient was noted to be cooperative and calm, and she was insightful in her psychological needs. The enrollee had outings outside of the residential treatment center, without significant concerns or behavioral issues. The progress notes did not indicate that the patient had psychosis, paranoia or mania symptoms during the residential admission. The records did not indicate severe psychiatric symptoms that would require intensive psychiatric care. The enrollee did not express suicidal ideation or severe mood lability during the disputed period. The enrollee did not have any self-harm behaviors and was medically stable. The medical record did not indicate the presence of withdrawal symptoms. The American Association of Community Psychiatrists Level of Care Utilization System assists providers in determining the necessary level of care for adults. In terms of risk of harm, the records support a score of 2 due to a lack of current suicidal ideation. With regards to functional status, the records support a score of 3 due to overall fair to good functional level. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no severe psychiatric symptoms. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment with family. 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 regards to treatment and recovery history, the records support a score of 3 due to minimal treatment response in the past with minimal noted treatment. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and apparent insight into need for treatment. Thus, the patient has a composite score of 16. This score correlates with an intensive outpatient treatment. The American Society of Addiction Medicine criteria can be applied to patients presentation to help determine the appropriate level of care. With regards to acute intoxication and/or withdrawal potential, the patient has a risk rating score of 0 due to lack of withdrawal. In terms of biomedical condition and complications, the patient has a risk rating score of 0 to 1 due to no active serious medical problems mentioned in the records. With regards to emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 0 to 1 indicating some mild depression issues that were noted to be under good control with antidepressant medications. With regards to readiness to change, the patient has a risk rating of 1 due to motivation to change and investment in treatment. In terms of relapse, continued use, or continued problem potential, the patient has a risk rating of 2 due to minimal sobriety. In terms of recovery/living environment, the patient has 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 consistent with intensive outpatient services. According to the scores on the two instruments above, the appropriate level of care for the patient was intensive outpatient care. Thus, residential treatment center services were 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.