Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee has requested reimbursement for the Residential Treatment Center (RTC) Services.The patient has a history of two previous treatments for the diagnoses of alcohol use disorder, with resulting relapse. The patient demonstrated significant cravings, depression, anxiety, and flashbacks. She did not recognize relapse triggers and demonstrated a lack of insight into the benefits of care. The patient made progress in addressing her alcohol use disorder, post-traumatic stress disorder (PTSD), and major depression. She was able to cope with emotions during telephone contact with her mother. The documentation showed a lack of evidence for the need for ongoing care at this level of RTC with a decrease in cravings, depression, anxiety, and flashbacks; and participation in recovery, and discharge planning. The patient has requested reimbursement for the RTC services that were provided. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. MD Analysis: At issue in this case is whether the RTC services provided were medically necessary for the treatment of the patients behavioral health condition.In this case, using American Society of Addiction Medicine (ASAM) 3.5 criteria, the patient met the criteria of in withdrawal and at risk for acute withdrawal. The records demonstrated that continued substance use was a serious risk to her health, having suffered a syncopal episode or seizure. After this date, the patients mental status sufficiently improved to permit participation in treatment. The patient showed little understanding of the effect of substance use on coping and functioning. She attributed her substance use problems to her relationship with her mother. She struggled to recognize that, without more intense care, her interactions with her mother would trigger relapse. The patient continued to experience strong cravings. Her recovery environment showed the risk of abuse. Therefore, RTC services that were received were medically necessary for the patients behavioral health condition. The records demonstrated successful completion of family interventions. The patient demonstrated the ability to manage her emotions and demonstrated improvement. Therefore, the medical necessity of RTC services that were provided has not been established. Final Result: The reviewer determined that the requested services were partially medically necessary for treatment of the patients medical condition. RTC services that were received were medically necessary for the patients behavioral health condition. The patient demonstrated the ability to manage her emotions and demonstrated improvement. The medical necessity of RTC services that were provided has not been established. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.