Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alcohol abuse/addiction.
Treatment:  Mental Health Residential Treatment.
The insurer denied the residential mental health treatment.  The denial was overturned.  

The patient presented for residential substance use disorder rehabilitation treatment to address severe alcohol use disorder.  The patient was not using other substances of abuse; she had no past history of withdrawal seizures, delirium tremens, or severe withdrawal symptoms, but she did report frequent blackouts in the context of alcohol use.  Her alcohol use had increased with more recent use of up to one-half water bottle of vodka daily including use while working.  She had a decline in functioning and family problems related to the alcohol use.  She was in treatment for co-occurring generalized anxiety and depressive disorders.  There was no history of suicidal behavior or psychiatric hospitalization.  She had prior substance use disorder treatment and had failed to remain abstinent while in outpatient treatment, including involvement in peer-supported recovery groups.

Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms.  She was fidgety and cooperative and superficially motivated for treatment in the contemplative stage of change.  She displayed mood disturbance with affective lability and with anxiety, as well as hopelessness, shame and guilt.  She 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.  She denied suicidal or homicidal ideation, and she had no aggressive impulses.  She reported sleep disturbance.  She had support from family, but reported anxiety and stress related to her family, especially in her relationship with her mother.  Her insight and judgment were characterized as limited and impaired with poor control of impulses.

The patient had no acute general medical conditions, and had chronic medical conditions that included a history of traumatic brain injury, polycystic ovary disease, obesity and type II diabetes mellitus, and her laboratory assessment showed elevated liver enzymes and dyslipidemia.  Urine drug screen was consistent with history.

The patient is single, college educated, and employed with job stress.  The patient lives alone.  Stressors included primary support, occupational, and social environment domains, as well as other psychosocial stressors associated with the alcohol use disorder and her general medical problems.

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.  She struggled to engage with treatment due to cravings and ongoing stress related to the family and to her affective disturbance/anxiety and insomnia.

She continued to struggle with craving addressed with anxiolytic medications and naltrexone and topiramate.  She was placed on a regimen of as needed (PRN) Seroquel and melatonin and trazodone, as well as vitamin and nicotine replacement therapy and supplements.  The patient had no complications of rehabilitation treatment, nor did general medical problems emerge.  She 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 12-step and Self-Management and Recovery Training (SMART) recovery groups with sober supports.  Her family participated in family focused sessions near the end of her residential stay including focus on the development of sober supports.  During her stay, the patient was considered at high risk for relapse; the risk diminished near the time of discharge, though she continued to display anxiety and dysphoric mood with insomnia.  She 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.  Her anxiolytic/antidepressant medications were continued, as well as naltrexone and topirimate for anti-craving.  At issue is the medical necessity of the residential treatment.

The health plan's determination is overturned.

The patient's severity of alcohol 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 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 admission and 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 conditions with unspecified anxiety and persistent depressive disorders, are other factors that support the necessity for residential level services through discharge, as well as the failure to remain abstinent while in treatment with lower level services.  The need for a disposition to intensive outpatient rehabilitation and mental health treatment with sober supports are other factors that support the necessity for continued residential level services toward the end of her residential stay, and these factors and treatment dimensions support the requested benefit through discharge in order to effect a safe and appropriate disposition.

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 acute residential level of care.  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 continued residential level services in keeping with prevailing standards of medical practice, ASAM Criteria, and the Scientific Literature, referenced below.  The requested residential substance use disorder treatment of alcohol use disorder could not have been effectively provided at a lower level of care.  Thus, the requested services are medically necessary in this case scenario in keeping with New York State OASAS LOCADTR 3.0 Criteria/Guidelines.

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.  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.