Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 36-year-old female with diagnoses of opioid use disorder, amphetamine use disorder, unspecified anxiety disorder, and unspecified depressive disorder. Prior treatment included admissions in 2010, intensive outpatient program (IOP) and sober living in 2011, as well as detoxification and admission in 2016, and hypnotherapy. She tried to self-detoxification and would relapse once a month, then in the year prior to this admission was unable to decrease or stop using. She was admitted on 7/22/16 and endorsed using intravenous (IV) heroin 1-2 gm a day, smoking methamphetamine 1 gram a day, and cannabis daily. Her longest period of sobriety was four months in 2012. The patient used alcohol in the past but not during the prior five years. She has a history of being tried on Subutex in May 2016, however she stopped and then relapsed. She attests to having prior delirium tremens and blackouts, but no seizures. She indicated that her father has a history of schizophrenia and her mother has borderline personality disorder. She has a history of anxiety and depression but was not admitted on any psychotropic medications. She attended individual, group, and family therapies, as well as biofeedback. On 8/10/16, she had anxiety and worked on feelings of guilt and dysfunctional beliefs. She was not a self-harm risk and her mood was appropriate. On this date, the patients goals were to become familiar with three dysfunctional life patterns and utilize this information in her individual sessions and group work. The patient has requested reimbursement for residential treatment center (RTC) level of care services provided from 8/11/16 through 9/4/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. Consistent with the current American Society of Addiction Medicine (ASAM) guidelines, the RTC level of care services provided from 8/11/16 through 9/4/16 were not medically necessary for treatment of this patients behavioral health issues. On 8/10/16, the progress records do not show any signs or symptoms of post-acute withdrawal. There was no evidence to suggest that she was a danger to herself or others. She was not gravely disabled. There were no emotional, behavioral, or cognitive issues impeding stepping the patient down to a lower level of care. She was not manic, psychotic, delusional, or impulsive to the point where she required the residential setting. Progress notes focused on the patients dysfunctional thoughts and beliefs, and there were no 12 step meetings documented. In addition, it is unclear if she underwent any type of detoxification protocol or was treated with any medications. Ongoing treatment of the patients anxiety and dysfunctional thoughts did not require the residential setting. These issues do not require 24-hour monitoring, and could have been rendered in an ambulatory setting. Therefore, the services at issue were not medically necessary.  Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.