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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance use residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. The American Society of Addiction Medicine recommends placement based on a complex, individual, clinical assessment rather than reimbursement limitations, program ideology, or utilization reviewers. The American Psychiatric Association recommends residential treatment 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. Additionally, the practice guideline jointly authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases:  There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment.  In this particular case, the patients alcohol use disorder was central to her daily routine and contributed to significant impairment across multiple functional domains. The patients daily consumption often culminated with black-outs. The patients placed others at risk by driving under the influence. The patients was socially isolative and having relationship strain with the patients spouse and family.  The patients was drinking at work and performing poorly in her sales job.  The patients did not have a sober social network while the patients spouse drank in the home and was not supportive.  The patients had medical problems secondary to her drinking.  The patient had a hospital admission in February 2017 for a lower gastrointestinal bleed, and diagnoses of gastritis, hypertension and hyperlipidemia, all of which are common sequelae of alcohol use disorder.  The patient also had co-occurring psychiatric issues, and was suicidal and wanted to die upon presentation.  As such, three days of residential treatment would have been inadequate to reconcile the issues that prompted the admission. Discharge to a community based venue, would have been inadequate. On 7/10/17, the patient was depressed and guarded. The patient initially felt forced into treatment but slowly began to embrace recovery.  Thereafter, according to the records provided, the patient was actively engaged in treatment during the entire admission including the addition of an anti-craving medication, acamprosate, family counseling and education, and aftercare preparation to develop a more empowering environment to sustain sobriety. The services and setting were safe, appropriate and consistent with community standards for a case of this severity. Additionally, the services provided at the time were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  In sum, considering the clinical presentation and perusal of the relevant peer reviewed literature, substance use residential treatment center services were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be 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.