Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Rehabilitation Services
The insurer denied the inpatient rehabilitation services.
The denial is overturned.

This case involves an adult female with severe alcohol use disorder who was admitted to inpatient residential level substance use disorder services following detoxification treatment and withdrawal management and after medical screening with plans for rehabilitation treatment and continued treatment of co-occurring mental disorders with anxiety and depression. Her presentation for residential level care was prompted by a break up with her fiance/significant other in the context of longstanding and continued use of alcohol with use of up to two bottles of wine daily. The alcohol disorder had onset in adolescence with progression of the disease and escalating use in the five years prior to admission. The increasing use of alcohol occurred in the context of a co-occurring anxiety disorder and grief related to the death of family members and severe psychosocial stressors including the break up with the fiance. The alcohol use had resulted in impairment of functioning with regard to social, occupational and daily functions with use throughout the day, putting her health at risk. The patient had no other significant past substance use disorder treatment. 

The patient presented with associated symptoms of anxiety and dysphoric mood with sad affect in the context of grief. There was no recent history of psychiatric hospitalization, and no mention of suicidal behavior except for one hospital stay as a teen. Psychotropic medications included Paxil 40 milligrams and as needed use of trazodone for sleep. She reported low energy and appetite.

The patient had no acute general medical issues. She had hypertension treated with amlodipine and metoprolol. Her exam and laboratory assessment and electrocardiogram (EKG) were otherwise normal or unremarkable except for markedly elevated liver functions and mean corpuscular volume (MCV) and cholesterol. The patient presented with acute withdrawal symptoms with a Clinical Institute for Withdrawal Assessment for Alcohol (CIWA) scale score of four, having just completed formal detoxification with vitamin replacement. She reported intense craving and tremor/shakes with elevated blood pressure.

Mental status examination included a kempt appearance with anxiety, dysphoria, and sad affect. Speech was clear and thoughts were circumstantial and tangential, but goal directed. She denied suicidal thoughts or ideas. There was no evidence for psychosis, mania, thought disorder, or severe cognitive impairment despite concentration difficulties. Insight was limited and judgment impaired due to the alcohol use disorder.

The patient had received detoxification treatment, and immediately transferred to inpatient residential level treatment with the structure, monitoring, and the intensity of residential level services. Treatment included group, individual, and educational services with the addition of non-pharmacologic interventions to address the anxiety disturbance, and emphasis on coping skills with the goal of the development of a relapse prevention plan and planning for a safe and appropriate discharge back to the community with partial hospital level care. She was prescribed Paxil and Acamprosate for craving (medication assisted treatment) with vitamin and nicotine replacement. 

The patient had engaged in treatment and was improving; she had received evidence-based interventions, and the patient's insight and mood had improved, as she was calm with euthymic mood with persistent reports of anxiety and less craving. The treatment team was recommending intensive treatment in the community with continued involvement in peer-supported recovery groups and sober supports or a sober living environment, and recommendations for the obtainment of a sponsor. Prognosis was guarded to fair and she was deemed to be at high risk for relapse unless continued treatment was to be provided. Discharge planning occurred as treatment continued with discharge and return to the community/home and plans for continued substance use disorder treatment and involvement in recovery groups with sober supports, as well as treatment from her primary care physician (PCP), and referral for psychotherapy. Medications were to be continued as noted.

Yes, the proposed treatment was medically necessary for this patient.

The continued inpatient residential level of services, structure, and monitoring provided in this case are warranted in view of the severity of the alcohol use disorder and associated symptoms of anxiety and depression, and complications of the alcohol disorder, as well as the intense craving that persisted up until the time of discharge. The patient could not have been effectively managed with lower-level services during the time interval under review contrary to the plan's reasoning for denial.

The continued residential level services through discharge were clinically appropriate and consistent with prevailing standards of medical practice, as well as the appropriate application of NY State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria that are meant to serve for determining an appropriate level of care, and indeed, the health plan covered the admission and inpatient residential stay for a certain time period. The services were provided with evidence-based treatments that are known to benefit patients with severe alcohol use disorder, as well as providing services to address treatment issues in a patient who presented with persistent withdrawal symptoms and craving, and general medical complications of an alcohol disorder and with high risk for relapse and continued liver damage. Thus, the patient's severity of alcohol use disorder and associated symptoms of  anxiety and depression in the context of severe psychosocial stressors did warrant and necessitate the continued inpatient residential level services, as proposed, and with the plan for step down to lower level services once the patient had stabilized with the ability to achieve abstinence with sober supports in working toward discharge plans and considering a safe and appropriate transition to the community with appropriate aftercare to include involvement with recovery groups and medication assisted treatment to address craving. 

Moreover, the patient presented with high risk for relapse in view of an inadequate recovery environment, a relative lack of coping skills and readiness to change, and a lack of sober supports despite some exposure to recovery groups. The additional time spent with motivational techniques and other interventions were essential to a successful therapeutic outcome in this case, especially since the patient was making progress and engaged in treatment and adherent to medications which the health plan had determined as reasons for not needing continued residential treatment. These clinical features and treatment dimensions did support the necessity for the continued inpatient level services and the continued structure and monitoring and intensity of services provided at the inpatient residential level of care through discharge.

This answer is consistent with the application of  New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, and with Level of Care Utilization System (LOCUS) Guidelines and the American Society of Addiction Medicine (ASAM) Criteria, and with the published guideline and the scientific literature, referenced below.

The application of Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria were not appropriately applied in this case; the health plan denied services  indicating that continued inpatient residential treatment is not necessary because there were no withdrawal symptoms, that the patient was medically stable with no psychiatric disorders requiring continued inpatient level care and that the patient was taking medications including medication assisted treatment (MAT) and was motivated for treatment and engaged in treatment with access to sober living and/or sober supports, as well as making progress. None of these reasons would support the level of care determination for the dates of service under review. The continued inpatient residential level of care in this case was medically necessary and consistent with the application of  New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, and with Level of Care Utilization System (LOCUS) Guidelines and the American Society of Addiction Medicine (ASAM) Criteria, and with the published guideline and the scientific literature, referenced below, as the appeal document asserts.