Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: 
The insurer denied
The determination is overturned.


This is a male patient who was referred for residential substance use disorder treatment to address substance use disorder with a stimulant class substance of abuse (methamphetamine) and co-occurring psychiatric disorders in the context of impairment of functioning and severe psychosocial stressors. The patient had one prior treatment episode with relapse and no significant period of abstinence or sobriety. He had used other substances of abuse recreationally including ketamine, gamma hydroxybutyrate (GHB), and alcohol, and he was tobacco dependent.
Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms such as mania, thought disorder, perceptual disturbance, or severe cognitive impairment. He was not clearly motivated for treatment in the pre-contemplative stage of change with a lack of insight and denial that the substance abuse was a problem. He was not clearly ready to engage in a recovery process, and had limited support due to family conflict and social isolation. The patient was described as having limited insight due to the addiction together with questionable judgment and extremely poor control of impulses. He denied active suicidal ideation or aggressive impulse. His energy and volition were impaired with poor appetite and concentration problems. Also, he had experienced and reported symptoms of anxiety and insomnia, as well as hopelessness and dysphoria with anergia and fatigue. The patient had no significant general medical conditions.
The patient underwent comprehensive psychiatric evaluation with admission to residential level services. Substance-related treatment included focus on coping skills, relapse prevention with identification of triggers, education about the disease model of addiction, and, involvement with peer-support recovery groups, as well as plans for family-focused sessions when clinically appropriate. Mental health treatment included groups, individual therapy including behavioral therapy, and access to psychiatric management. He was prescribed vitamin supplements and melatonin, as well as the availability of nicotine replacement.
From the date of admission forward, the patient had variably engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program and therapeutic milieu. He was not well motivated due to maladaptive coping and comorbid disorders, and a lack of insight and motivation to change. He was cooperative, but continued to display a lack of insight and immaturity regarding impulse control and his stage of change. Nonetheless, he did participate in the rehabilitation treatment with plans to continue with residential level services with clinically appropriate step down. The patient continued participating in the treatment with a focus on coping skills and continued involvement with behavioral interventions including evidence-based psychosocial interventions, and involvement in recovery groups with peers and medication management. He struggled, had to be directed to complete assignments, and was developing a relapse prevention plan. 
At issue is the medical necessity of chemical dependency residential treatment. 
The requested health service/treatment of chemical dependency (CD) residential treatment (RTC) was medically necessary for this patient.
The patient did meet ASAM Criteria and continued to warrant the structure, monitoring, and intensity of level 3.5 residential treatment for the duration of the residential stay under review. The patient's lack of awareness or limitations of insight together with the seriousness of the comorbid psychiatric disorders and co-occurring substance use disorders is illustrated by his continued risk for problematic behavior and continued risk of relapse with use of a high-risk substance of abuse including the functional decline that had occurred despite having access to treatment in the community, and in the context of maladaptive coping skills and substantial psychosocial consequences.
The patient's lack of awareness or limitations of insight together with the seriousness of his psychiatric disorders and co-occurring substance use disorders is illustrated by his continued risk of relapse with use of a high-risk substance of abuse including the functional decline that had occurred despite having access to treatment in the community, and in the context of maladaptive coping skills.
The requested benefit of the continued residential treatment was medically necessary in order to address the immediate needs for rehabilitation of severe substance use disorder and to work toward relapse prevention; and in order to address the patient's lack of awareness and impulse control; and, in order to address issues within the social environment; and, in order to work on coping skills that will be necessary in building a sober support system and planning for continued recovery efforts with community providers and engagement with age-appropriate recovery groups, and, services to address the anxiety and trauma-related symptoms.
The development of a relapse prevention plan is critical in this case together with gains with insight and acquisition of better coping skills that are important components of the treatment being provided with clinically appropriate residential structure, intensity of services, and monitoring. It is therefore medically necessary that the patient have continued 24-hour monitoring and high intensity residential level services for the duration of the proposed treatment in order to prepare the patient for a safe and clinically appropriate disposition and discharge to the community. None of this therapeutic work could have been or can be safely or effectively provided at a lower level of care in view of the multiple, complicating factors in this case for the time interval under review.
This answer is consistent with prevailing standards of professional practice and ASAM Patient Placement Criteria and the published guidelines and scientific literature, referenced below, and is consistent with New York State OASAS LOCADTR Criteria.