Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Mental Health Services
The health plan denied.
The determination is overturned.

The patient is an adult male who presented for residential substance use disorder rehabilitation treatment to address severe opioid, stimulant (cocaine and Adderall), alcohol, and cannabis use disorders, as well as intermittent use of non-prescribed benzodiazepines. The patient had no past history of withdrawal seizures, delirium tremens, or severe withdrawal symptoms, but did report frequent blackouts in the context of alcohol use with a binge pattern of use together with other substances. His substance use began in adolescence and had increased with more recent use resulting in family conflict and other psychosocial consequences; he had a decline in functioning and family problems related to the substance use. He was in treatment for co-occurring generalized anxiety and depressive disorders. There was no history of suicidal or self-harming behavior, but his substance use did result in high risk behaviors due to intoxication and blackouts. He had prior substance use disorder treatment and had failed to complete treatment or remain abstinent.
Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. He was fidgety/restless and cooperative and superficially motivated for treatment in the contemplative or pre-contemplative stage of change. He displayed mood disturbance with affective lability and anxiety. He had soft spoken speech and circumstantial and tangential thought processing with racing thoughts. There was no evidence for psychosis, thought disorder, severe cognitive impairment or perceptual disturbance. He denied suicidal or homicidal ideation, and he had no aggressive impulses. He reported sleep disturbance. He had support from family, but reported anxiety and stress related to his family. His insight and judgment were characterized as limited and impaired with poor control of impulses.
The patient had no acute general medical conditions, and an electrocardiogram (EKG) and laboratory assessment were unremarkable or normal. A urine drug screen was consistent with the history.
The patient received residential rehabilitation treatment that included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with 12-step recovery groups as well as family-focused sessions. The patient engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program. He struggled to engage with treatment due to cravings and ongoing stress related to the family and to his affective disturbance/anxiety and insomnia.
He continued to struggle with craving and post-acute withdrawal symptoms that were addressed with anxiolytic medications. He was placed on a regimen of venlafaxine, Seroquel and melatonin and trazodone, as well as vitamin replacement therapy and supplements. The patient had no complications of rehabilitation treatment, nor did general medical problems emerge. He gradually engaged with the rehabilitation program with full participation and became increasingly motivated, gaining insight and additional knowledge of a recovery process. She was committed to continued involvement with recovery groups and effort to develop sober supports. During his stay, the patient was considered at high risk for relapse; the risk diminished near the time of discharge/step down though he continued to display anxiety and dysphoric mood with insomnia and Post-Acute Withdrawal Syndrome (PAWS). He was stepped down to lower level services with plans for continued rehabilitation treatment, family-focused therapy, and continued involvement with recovery groups including the obtainment of a sponsor. 
The issue under review is the medical necessity of residential substance use disorder treatment.

The requested services are medically necessary for this patient.
The patient's severity of substance use disorder, risk of relapse, and lack of sober supports do support the medical necessity for an admission and continued treatment at the residential level of care. 

The residential level rehabilitation treatment provided was reasonable, in the best interest of the patient, and was provided with sound medical judgment in keeping with evidence-based and empirical based practice. The patient's lack of insight and coping skills, planning for family-focused sessions to develop sober supports, as well as efforts to address co-morbid psychiatric conditions with anxiety and depressive disorders, are other factors that support the necessity for residential level services through discharge, as well as the patient's failure to remain abstinent while in treatment with lower level services or inability to maintain a treatment effort in the recent past. The need for a disposition to intensive day rehabilitation and mental health treatment with sober supports are other factors that support the necessity for continued residential level services toward the end of his residential stay. These factors and treatment dimensions support the requested benefit through discharge in order to effect a safe and appropriate disposition.
The patient could not have been effectively treated at a lower level of care during the time interval under review, and does meet medical necessity for the residential level services in keeping with prevailing standards of medical practice, ASAM Criteria, and the Scientific Literature, referenced below.
The patient's lack of insight and coping skills as well as co-morbid psychiatric conditions are factors that warranted the admission and the continued necessity for residential level services through discharge/step down. The need for a disposition with sober supports and family-focused therapy to address the issues within the family constellation are other factors that support the necessity for continued residential level services and the requested benefit through discharge with step down for continued services.
The requested services could not have been effectively provided at a lower level of care. Thus, the requested services are medically necessary in keeping with New York State OASAS LOCADTR 3.0 Criteria/Guidelines.