Appeal type: Medical necessity
Decision: Overturned

Alcohol Abuse/Addiction
Substance Abuse: Residential

The patient is a male who presented for residential substance use disorder rehabilitation treatment to address severe alcohol use disorder. The patient was not using other substances of abuse; he had no past history of withdrawal seizures, delirium tremens, or severe withdrawal symptoms. The patient had been using alcohol for 33 years and his alcohol use had increased in the twenty years prior to presentation with more recent use of up to six drinks daily. He had a decline in functioning and marital problems though he maintained his employment. He reported co-occurring depression and anxiety in the past that was treated off and on. There was no history of suicidal behavior or psychiatric hospitalization. He had no prior substance use disorder treatment and reported no periods of sobriety. Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms. He was cooperative and superficially motivated for treatment. He displayed anxiety and euthymic mood and a full range of affect with fluent, articulate speech. There was no evidence for psychosis, thought disorder, cognitive impairment or perceptual disturbance. He denied suicidal or homicidal ideation and had no aggressive impulses. He displayed anxiety and dysphoria. He reported sleep disturbance. He had support from family (sibling), but reported anxiety and stress related to his spouse. His insight and judgment were characterized as limited and impaired with poor control of impulses. The patient received detoxification and slow engagement with 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 was judged to be in the precontemplative stage of change and received 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 marriage with affective disturbance/anxiety and insomnia treated with supportive measures and trazodone.The patient he continued to struggle with post-acute withdrawal symptoms and craving. He was prescribed vitamin replacement therapy and supplements. The patient had no complications of rehabilitation treatment, nor did general medical problems emerge. He participated in the rehabilitation program with full participation and became increasingly motivated, gaining insight and additional knowledge of a recovery process. He was committed to continued involvement with 12-step recovery groups with sober supports. His sibling/family participated in focused sessions near the end of his residential stay including focus on the development of sober supports and an aftercare plan.
During his stay, the patient was considered at high risk for relapse due to the limited supports and lack of a reasonable recovery environment. His discharge diagnosis was severe alcohol use disorder and he had been diagnosed with an unspecified anxiety disorder during his stay with resolution of the symptoms of anxiety and continued use of trazodone to address his insomnia. The health plan's determination is overturned. The patient was considered at high risk for relapse due to the limited supports and lack of a reasonable recovery environment. The patient's lack of insight and coping skills as well as co-morbid psychiatric condition are factors that support the continued necessity for residential level services through discharge. The need for continued treatment 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. The patient could not have been effectively treated at a lower level of care during the time interval under review in keeping with prevailing standards of medical practice, American Society of Addiction Medicine (ASAM) Criteria, and the Scientific Literature, referenced below. Based upon the diagnoses, mental status and clinical course, the patient did warrant the continued structure and monitoring and intensity of services provided by the residential program through discharge. 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, the need for family-focused sessions to develop sober supports, as well as co-morbid psychiatric condition with unspecified anxiety, are other factors that support the necessity for continued residential level services through discharge. The need for an appropriate and safe disposition is another factor that supports the necessity for continued residential level services and the requested benefit through discharge.