Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Substance Use Disorder
Treatment: Substance use rehabilitation residential treatment
The insurer denied substance use rehabilitation residential treatment.
The determination is partially overturned.

The patient was admitted for residential substance use disorder and mental health treatment of cannabis and alcohol use disorders and co-morbid post-traumatic stress disorder (PTSD) associated with anxiety and depression and other symptoms following a rape. The patient was treated immediately prior to her referral for worsening symptoms of depression and anxiety together with the substance use and onset of suicidal and self-harming behavior (cutting), prompting her referral by outpatient providers and the family. The patient's functioning had declined in the context of the behavioral disturbances associated with anxiety and depression with affective instability triggering the use of cannabis, as well as use of alcohol and tobacco (nicotine).

The patient presented with anxiety and affective instability with limited insight and impaired judgment associated with anxiety symptoms that were prominently related to trauma history (rape); she exhibited coping and personality traits that reflected poor control of impulses with high risk for suicide or self-harm.

There were no acute general medical conditions or other substantial substance use disorders in this case, but the patient did present with substance use with cannabis which was the drug of choice and was increasingly problematic and severe.

The patient lives with her parents. The patient is a high school student. She has no legal issues, but had a significant trauma history as noted.

The patient presented for residential treatment with a treatment plan to address the primary diagnoses of cannabis and alcohol and nicotine use disorder, PTSD, and family dynamics; she received a comprehensive psychiatric evaluation with plans for medication management of the anxiety-depression and PTSD. Medications included buspirone and melatonin and hydroxyzine to address anxiety and insomnia.

The patient had made steady progress including efforts to address the severe psychosocial stressors and planning for resumption of her education. The patient continued mental health services with intensive multimodal therapy and safety monitoring together with the intensity of treatments and structure of a residential level of care with safety monitoring. She received ongoing psychiatric evaluations with revisions of a treatment plan that was focused on a recovery process and sustained abstinence from substances, trauma recovery, family-focused sessions, and coping skills with work on a relapse prevention plan. The treatment plan included therapeutic interventions to improve coping skills and self-esteem, and the treatment plan included the goals of breaking the cycle of self-destructive behaviors including impulsivity or self-harm; and, the development of healthy relationships and functioning that included weekly family-focused sessions and use of evidence-based techniques such as mindfulness. The patient's treatment was complicated by a lack of insight, the news of a friend who died by suicide, and the trauma-related symptoms posing a high risk for relapse and need to work toward better coping skills.

Going forward, the program continued the focus on organizational skills with educational assignments, self-care, peer relationships, and other life skills, as well as behavioral and emotional regulation with milieu, individual, group, family, and activity therapies, as well as other interventions aimed at improving life skills and better coping. The patient actively participated in the treatment plan and worked on therapeutic, social, and emotional functions in the context of a therapeutic milieu with a residential level of structure and monitoring with a behavioral health program that utilized levels, and a therapeutic setting that provided structure, intensive and evidence-based therapy, and safety monitoring, as well as ongoing interventions to address impulsivity and improve insight. Life skills and other age-appropriate therapeutic interventions were provided, as the program would allow. Additionally, the patient received therapy to assist her to process the issues associated with the trauma and identify triggers for the substance use.

The patient had made steady, but uneven progress with the therapeutic interventions while working on communication skills with peers and family alike. The treatment team and family addressed boundary issues pertinent to a recovery process, and the patient actively participated in treatment to improve control of impulses and frustration/distress tolerance related to the trauma. Behavioral therapy was provided throughout her stay in order to address dysregulation of mood, distress, and interpersonal functioning and to prevent regression or relapse. She had gained insight and had no episodes of problematic behaviors requiring staff intervention or loss of privileges. She received continued treatment with medications and ongoing psychiatric management.

The patient was noted to display euthymic mood, diminished anxiety, and better coping skills and was doing well. She had resisted engaging in self-harming or aggressive behavior towards self; family intensive treatment had occurred with subsequent processing of family issues related to boundaries and impulse control and coping. The patient was preparing for a clinically appropriate step down to lower-level services. The patient's motivation and engagement with treatment had clearly improved and the patient was noted to be more socially appropriate with improved control of impulses and better mood with diminished anxiety, as well as progress with the therapy while maintaining contact and treatments with family. For the remainder of the residential stay, the patient's mood remained stable and she was noted to be working on issues with good progress with therapeutic endeavors. Again, the patient continued to participate in the residential program with discharge/step down to outpatient level care and return home with continued mental health services and clinically appropriate aftercare to address the substance use disorders. Her family had remained supportive and the patient had been actively participating in a therapeutic process with focus on better coping and the development of better communication skills, while continuing with her medication regimen for PTSD and depression-anxiety.

The case records and health plan documents were reviewed including correspondence and case notes and New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3 medical necessity criteria. The health plan's rationale for the denial of the requested services was reviewed together with the appeal for the dates of service under review. The review is New York State mandated with the application of NY State OASAS LOCADTR 3 Criteria.
At issue is the medical necessity of continued residential substance use disorder and mental health treatment.

The services were medically necessary in part.

The patient required the admission and warranted the continued structure and monitoring of a residential setting that was medically necessary in order to effectively address the patient's risk for impulsive and problematic behaviors including risk for self-harm, continue to learn adequate coping skills to achieve better control of impulses and work on relapse prevention, while the treatment team and family worked toward a clinically appropriate disposition with continued mental health services to address the co-occurring mood and anxiety symptoms associated with PTSD and to effectively address the co-occurring substance use disorders. The patient had residual symptoms and behaviors that had persisted despite past treatment prompting the referral to residential care and the patient continued to lack the insight and control of impulses to remain engaged in treatment in a less restrictive setting during this time frame.

The clinical presentation and acuity of symptoms and complicated psychosocial factors in this case together with the treatment dimensions with regard to American Society of Addiction Medicine (ASAM) Criteria are the reasons that the admission and continued residential level services do meet medical necessity with the application of New York State OASAS LOCADTR Criteria, as well as prevailing standards of medical practice and in keeping with the guidelines referenced below. Again, the patient's admission and treatment is reasonable and in the best interest of the patient; she presented with severe symptoms of depression and anxiety, suicidal ideation and behaviors associated with unresolved grief/trauma triggering the substance use, and outpatient treatment had failed to prevent increasing symptoms of depression and suicidal ideation and self-harming behavior in the context of severe psychosocial stressors and substance use.

The patient could not have been effectively treated at a lower level of care until the patient was stable with euthymic mood and was effectively working on the remaining psychological issues with improved insight and impulse control and coping skills per the health plan's case notes and case records. Thus, the requested services of residential level treatment for 27 days are reasonable and consistent with prevailing standards of medical care, and with the application of NY State OASAS LOCADTR 3 Criteria, referenced below. Services after that are not medically necessary.

This answer is consistent with the scientific literature and guidelines referenced below, and with the application of NY State OASAS LOCADTR 3 Criteria, referenced below.