Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse.
Treatment:  Residential Rehabilitation.

The insurer denied the residential rehabilitation.  The denial is overturned. 

The patient is a adult male admitted for residential rehabilitation and substance use disorder treatment of alcohol, opioid and stimulant (cocaine) use disorders.  His rehabilitation treatment included the continued use of medication assisted treatment with methadone.  The patient has no history of withdrawal seizures or delirium tremens.  He was admitted with persistent withdrawal or post-acute withdrawal symptoms (PAWS) with craving at the time of admission.  He has a history of poly-substance use disorder with more recent daily continuous use of heroin, alcohol and cocaine.  The patient has a history of past treatment episodes including past involvement with Alcoholics and Narcotics Anonymous, as well as medication assisted treatment.  Despite the best efforts of community providers, the patient had relapsed with use of heroin, alcohol and cocaine.

The patient is homeless and relies on others for housing.  He is unemployed.  There is no report of current legal issues or trauma history in this case.

The patient received comprehensive treatment that included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and, involvement with groups, as well as involvement in 12-step recovery groups and other therapeutic activities. 

Yes, the proposed treatment, residential rehabilitation substance use disorder treatment, was medically necessary for this patient and is consistent with NY State OASAS LOCADTR 3.0 Criteria.

The requested benefit of residential rehabilitation substance use disorder treatment is considered clinically appropriate and medically necessary in order to address the immediate needs for rehabilitation of the severe substance use disorders diagnosed in this case, and to work toward relapse prevention in a patient with high risk for relapse.  The admission and continued inpatient rehabilitation treatment was warranted in order to address the patient's lack of awareness of the seriousness of his illnesses with psycho-education and evidence-based psychosocial interventions, in order to address issues within the social environment, in order to work on coping skills that will be necessary in building a sober support system, and necessary for continued recovery efforts with community providers and re-engagement with peer-supported recovery groups that had been effective in the past.  The counseling, educational sessions, and the development of a relapse prevention plan were critical in this case, together with the motivational techniques that served to facilitate gains with insight and acquisition of better coping skills - all important components of the treatment that were provided with clinically appropriate structure, intensity of services, and monitoring.  It was clinically appropriate and medically necessary that the patient have 24-hour monitoring and inpatient level services prior to step down to lower level treatment and that he be provided continued inpatient 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 effectively provided at a lower level of care in view of the multiple, complicating factors in this case for the time interval under review.