Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cannabis Addiction

Treatment: Continued residential treatment center care

The insurer denied coverage for continued residential treatment center care.

The denial is upheld.

This patient was admitted to this inpatient substance residential treatment due her cannabis addiction. She reportedly was using cannabis daily and it was reported that drug dealers were coming to the house. She reportedly also had depressed mood and anxiety as well as ADHD (attention deficit hyperactivity disorder) symptoms. She reportedly had a past suicide attempt and past psychiatric hospitalization. She reportedly had a family history of substance and mental health issues. She reportedly denied other substances of abuse of alcohol abuse. She reportedly was living with her parents and brother. She reportedly had a history of lying, stealing, sexual behavior, and was noncompliant with taking her medications. She reportedly was prescribed Prozac and Vyvanse. She reportedly attended individual and group therapy. 
 
The APA (American Psychiatric Association) Practice Guidelines for the Treatment of Patients with Substance Use Disorders states that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. The medical records did support that she required 24 hour inpatient substance residential treatment from admission as she had difficulty stopping cannabis use and put herself in dangerous situations due to use including having drug dealers go to the house. However, the medical records did not provide specific evidence that she still only required this level of care then could not be treated in a less restrictive level of care then. It was reported that on she had high motivation to live a sober life and was able to process events and reported a mood of 9 out of 10. 

Towards the ending of her stay, there were no reported specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour inpatient substance residential setting or that could not be achieved in a less restrictive setting. There were no reports of life threatening or severe withdrawal symptoms or acute medical instability that would have required 24 hour treatment. In this case this patient did require substance treatment to learn better coping skills, identify relapse triggers, and improve relapse prevention skills and she reportedly was in this inpatient residential treatment and made progress but the chart notes did not provide enough evidence to support that she only required 24 hour substance residential treatment forward.

Continued substance inpatient residential treatment forward was not medically necessary.  It appeared that the health care plan acted reasonably and with sound medical judgment. 

Based on the above, the medical necessity for the continued residential treatment center care is not substantiated. The insurer's denial is upheld.