Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided on 3/7/18 to 3/27/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee's behavioral health condition.At issue in this case is whether the requested residential treatment center services provided from 3/7/18 to 3/27/18 were medically necessary for treatment of the enrollees behavioral health condition.The patient was admitted to the residential treatment facility on 2/26/18 with diagnoses of stimulant use disorder, cocaine, severe; alcohol use disorder, mild; and trichotillomania. A review of the records provided for the dates in question indicate that the patient denied any suicidal or homicidal ideation and did not have any abnormal thoughts or psychosis. The patient was cooperative with clear speech, euthymic/bright mood and full affect. He was not showing any medical issues which interfered with his treatment and care. In cases such as this an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining the necessary level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to some problems with comorbidity. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 1 due to overall medical stability. In terms of level of stress of the recovery environment, the records support a score of 1 due to a stable living situation. With regards to level of support for the recovery environment, the records support a score of 1 due to family support and availability of treatment resources but also some difficulty in relationships with his family members. With regards to treatment and recovery history, the records support a score of 2-3 due to recent success at the residential treatment center level of care. In terms of engagement and recovery status, the records support a score of 1 due to cooperation in treatment and insight into his need for treatment along with insight into his treatment needs. Thus, the patient has a composite score of 9-10. This correlates with treatment in a community-based outpatient clinic setting. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment of substance use disorders. All told, the requested residential treatment program services were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients behavioral health condition.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.