Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Substance use disorder services-residential.

The insurer denied substance use disorder services-residential.  The determination is upheld

The patient was admitted to residential level services for treatment of substance use disorder (alcohol and cannabis); the patient had been using marijuana on a daily continuous basis with alcohol use on an intermittent basis. He had a history of substance use beginning in 8th grade. The patient was motivated to enter substance abuse rehabilitation treatment and was supported in his effort by his family with whom there was stress over his use.

The patient had no past history of withdrawal seizures or delirium tremens. He had no past history of formal substance use disorder treatment other than outpatient counseling.
The patient was diagnosed with generalized anxiety and unspecified depressive disorders. He was taking Zoloft 50 milligrams (mg) daily, which had been switched from Lexapro.

The patient had no acute or chronic general medical issues. There is a history of concussions incurred during sports. He was medically screened prior to admission, and his laboratory assessment was normal or unremarkable with drug screen positive for tetrahydrocannabinol (THC)-consistent with his history. He was tobacco dependent.
The patient is single and attends college and lives with family. There is no report of legal issues or trauma history.

A Mental Status Examination revealed symptoms of depression and anxiety without suicidal ideation or psychotic features. His speech was clear; thoughts were disorganized, but logical and goal directed; and insight was fair with impaired judgment. Post-Acute Withdrawal Symptoms were mild with craving.

The inpatient level substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, education and peer-supported recovery groups. Medications included continued use of Zoloft titrated to 100 mg and nicotine replacement therapy, and comfort medications as needed. The patient engaged in substance use disorder rehabilitation treatment with active involvement in group and educational sessions, as well as other therapeutic interventions to support healthy living and the development of sober supports. In this regard, the patient worked on coping skills and a relapse prevention plan with the identification of triggers including the negative influence of depression and anxiety. He participated in dialectical behavioral interventions including mindfulness training.

The patient reported feeling better and was engaged in treatment. He was described as motivated. He was tolerating the Zoloft and was sleeping and eating okay. He was making progress with the treatment plan and was noted to be committed to a recovery process. He did report craving for tobacco but was otherwise without withdrawal symptoms. The patient continued with the residential program without complication. He was discharged with referral for outpatient aftercare for the co-occurring substance-related and mental health conditions, and recommendation to participate in family-focused or peer-supported recovery groups as clinically appropriate. He returned to his home with family supports with the goal of returning to college.

Case records and the health plan documents, appeal documents, correspondence from the health plan and advocate, as well as the health plan's case notes and rationale for denial of the requested inpatient rehabilitation services were reviewed. Additionally, the Certificate of Coverage with the schedule of benefits and plan language and health plan's Behavioral Health Services Policy was reviewed, as submitted. This is a New York State mandated review including the application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria 3.0.

The issue under review is the medical necessity of Residential Rehabilitation Substance Use Disorder Treatment.

The requested health service/treatment of substance use disorder services-residential treatment was not medically necessary for this patient.

The services could have been safely and effectively provided at a lower level of care in this case scenario. The patient was using marijuana regularly with intermittent use of alcohol; and the patient exhibited symptoms of anxiety and depressive disorders without severe symptoms such as psychosis or suicidality. There were no co-morbid general medical problems, or psychiatric symptoms/disorders in this case, that would have warranted the continued residential level services, structure or monitoring. The patient was motivated to remain engaged in treatment, had responded well to the initial treatment following an evaluation and medical screening, and the patient had access to sober supports/sober living and peer-supported recovery groups in the community. The patient had a sober home and family support; and the patient had successfully engaged in substance use disorder treatment in view of the motivating factors in this case. The psychosocial stressors and co-occurring psychiatric disorders were not so severe to prevent effective and safe treatment in a less restrictive environment with lower level care and sober housing or supports.
 
The structure and intensity of services necessary for a continued and successful rehabilitation treatment can be effectively provided at a lower level of care in a less restrictive treatment setting; moreover, the patient had not previously been exposed to formal and intensive rehabilitation treatment; thus, there is no evidence that residential level structure and monitoring was medically necessary for a successful outcome. There were no biomedical, psychiatric or general medical issues that necessitated continued residential level treatment following the initial evaluation and treatment.

These answers are consistent with prevailing standards of professional practice, American Society of Addiction Medicine (ASAM) Criteria, published practice guidelines, and the scientific literature, referenced below, as well as the New York State OASAS LOCADTR Criteria applicable in this case.