Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/ Case Summary: The enrollee has requested authorization and coverage for residential drug rehabilitation with a detoxification program. The preadmission assessment noted the enrollees drug of choice is methamphetamines, as well as alcohol.    The enrollee was utilizing one gram of methamphetamines daily.  She complained of having nightmares, night sweats, frequent awakening and difficulty falling asleep.  Appetite was good and she had gained 10 to 20 pounds in the last two months.  She had no recent or previous suicidal or homicidal ideation. She was previously charged with possession and lost her job because of her use.  Her motivation and initial insight were good.  The enrollee was previously treated in residential treatment care for one day but left against medical advice.  She was tired, numb and self-medicated because she was sad.  The enrollee did have high-risk behaviors, as indicated by driving under the influence and thrill-seeking.  Psychosocial stressors include family, job, financial, social support and chronic relapse. The enrollee has feelings of depression, sadness, anxiety, restlessness, emotional disconnection and trouble with recall/memory. The medical literature indicates clinically managed high-intensity residential services for adults, provides 24-hour care with trained counselors to stabilize multidimensional imminent danger and prepare for outpatient treatment. Enrollees in this level are able to tolerate and use full active milieu or therapeutic communities. This level encompasses residential services that are described as co-occurring capable, co-occurring enhanced, and complexity capable services, which are staffed by designated addiction treatment, mental health, and general medical personnel who provide a range of services in a 24-hour treatment setting. The psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the enrollees safety, but also to promote improvement in the enrollees condition. The determination of an appropriate setting for treatment should include consideration of the enrollees symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning. According to the record, the enrollee utilizes alcohol and methamphetamines with active symptoms present.  She is depressed and has a potential for relapse, which places her at risk of immediate danger outside of treatment in a residential care.  Her environment is considered to be highly stressful and minimally supportive.  Services at the proposed level of care are appropriate for this enrollee.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Addiction Medicine 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 similar medical condition.