Appeal type: Medical necessity
Decision: Overturned

This is a patient referred following inpatient detoxification treatment for residential substance use disorder treatment to address severe alcohol use disorder. The patient has a longstanding history of alcohol use disorder with past treatment including abstinence and sobriety for no more than six to 12 months. The patient presented with continuous daily use of alcohol in large quantity including showing up to work intoxicated. He presented with symptoms of anxiety that were contributing to his alcohol use. He has a history of depressive disorder and posttraumatic stress disorder. The patient has a past history of driving while intoxicated (DWI) arrest but no current legal issues. He had motivating factors related to the psychosocial stressors including primary support, occupational and economic domains that included relationship problems with his significant other. There was no history of severe withdrawal symptoms such as delirium tremens and withdrawal seizures.
General medical screening revealed no acute medical issues. Chronic conditions included gastroesophageal reflux disease (GERD) and a past history of hypertension.
The patient is housed and living with his significant other. He was college educated and employed with job jeopardy. There were no prominent legal issues, as noted, and a family history of alcoholism reflecting genetic predisposition. He has a trauma history including friends that died from suicide.
Evaluation on admission to inpatient level services revealed a mental status examination that was free of severe psychiatric symptoms such as mania, thought disorder, psychosis, perceptual disturbance or suicidal ideation. He was motivated to engage in substance use disorder and rehabilitation treatment and re-achieve sobriety. Mental status examination showed euthymic mood, anxious affect with irritability and withdrawn demeanor. He reported insomnia, low energy, fatigue and poor concentration. He reported intense cravings and post-acute withdrawal symptoms (PAWS). Insight, judgment and impulse controls were limited, impaired and poor.
The patient's treatment included intensive services, monitoring, and residential level structure. The patient participated in recreational/activity therapies designed to support sober living and life skills together with group, individual and educational sessions. He readily engaged in substance use disorder treatment. Again, he had mild withdrawal or post-acute withdrawal symptoms during his stay that included anxiety, irritability, abdominal cramps and nausea. He was prescribed Wellbutrin to address mood and anxiety and trazodone and vistaril to address anxiety and insomnia, as well as vitamin replacement therapy.
At the time of admission to rehabilitation treatment through discharge, the patient was readily participating in groups and educational sessions, and involved in 12-step recovery groups, as well as other therapeutic interventions to improve motivation with focus on developing coping skills, a relapse prevention plan with identification of triggers, and stress management techniques.
The health plan's determination is overturned
The patient's admission to residential level services with the continued structure and monitoring was necessary in order to effectively address the risk for relapse, develop a relapse prevention plan and work on coping skills to remain engaged in rehabilitation treatment, to address family issues with his significant other with a detailed psychosocial assessment, and consider other psychosocial issues pertinent to his substance use disorders including the need for sober supports, and develop a transition plan that would effectively prevent treatment failure while working on the occupational and economic stressors. These treatment factors and clinical features did necessitate the admission and the continued structure and monitoring of a residential setting with development of a treatment plan and determination of the clinically appropriate level of care for step down. The psychiatric co-morbidity (mood and anxiety disorders) and severe psychosocial stressors did initially complicate this case, as the patient had symptoms of anxiety and post-acute withdrawal symptoms (PAWS) that were at risk for triggering the substance abuse, as well as stressors that were related to the quantity of alcohol used in the context of a lack of sober supports and a sober recovery environment. The patient could not have been effectively treated at a lower level of care.