Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse; Mood disturbance.
Treatment: Residential Mental Health Treatment Services.

The insurer denied the Residential Mental Health Treatment Services.  
The denial is overturned.

The patient is a adult male. Following a relapse, he was admitted to inpatient residential level substance use disorder rehabilitation services with admission. His presentation for mental health and substance use disorder treatment was prompted by a relapse that included binge drinking alcohol and a manic episode with psychotic features. He had experienced a precipitous decline in functioning in the context of escalating use of substances including alcohol, cannabis and stimulant class substances together with co-occurring psychiatric disorders, bipolar I disorder and history of attention deficit hyperactivity disorder (ADHD) and obsessive- compulsive disorder (OCD). The patient presented with associated symptoms mood disorder with paranoid thinking, grandiose delusions, auditory hallucinations and mixed mania together with binge drinking up to 12 beers and six shots of tequila, as well as daily use of cannabis/marijuana. He had also misused his Vyvanse in the past.

The patient provided a history of psychiatric treatment for bipolar mood disorder or schizoaffective disorder with history of psychotic features and obsessive-compulsive related symptoms that were unspecified. He had prior suicidal behavior and treatment at varying levels of care including inpatient, partial hospital program (PHP) and intensive outpatient program (IOP) treatment. His onset of mental disorder was in his early years with subsequent use of substance use as an adolescence. The patient has a history of mental health and substance use disorder treatments going back to childhood including recent inpatient and residential level treatment with step downs to PHP (partial hospital program) and IOP (intensive outpatient program) levels of care, respectively. Nonetheless, the patient resumed binge drinking triggered by the mood disturbance and resulting in re-admission to residential level care with 24-hour safety monitoring and intensive residential treatment.

The patient had no acute medical issues. Laboratory assessments were normal or unremarkable with a positive drug screen consistent with history.

The patient is single and unemployed and a student. He lives with family. He has not had legal issues or trauma history.

The patient's mental status examination included mixed features of mania and dysphoric irritability. Speech was clear and thoughts were disorganized and erratic with grandiose delusions and paranoid thought content, as well as religiosity. He denied suicidal thoughts or ideas. There was perceptual disturbance with auditory hallucinations or severe cognitive impairment (executive function deficits) with concentration difficulties. He reported low energy and sleep disturbance. Insight was limited and judgment impaired due to the substance use disorder and psychosis, and he had poor control of impulses.

The residential level treatment provided structure, monitoring, and the intensity of residential level services. The residential program included intensive rehabilitation services with sober housing and monitoring for abstinence. Treatment included group, individual, family-focused, and educational services with emphasis on coping skills, and with the goal of the development of a relapse prevention plan. He received vitamin replacement therapy and psychotropic medications included Risperdal Consta and Wellbutrin with the latter targeting the ADHD (attention deficit hyperactivity disorder). There was the opportunity to participate in 12-step recovery groups with assignments, and he worked with peers to address relapse issues and identification of triggers to use alcohol and cannabis. The patient struggled with PAWS (post-acute-withdrawal syndrome) that diminished with persistent craving, and sleep disturbance, as noted with prn (as needed) medications. During his brief inpatient residential stay, the patient continued to display co-occurring symptoms of the mood disorder with psychosis and struggles with maintaining abstinence and the lack of coping skills. The patient made steady progress, but required ongoing monitoring to assure abstinence and therapeutic interventions to address interpersonal problems and anger issues best characterized as borderline personality disorder; he was exposed to dialectical and cognitive-behavioral therapy (DBT & CBT), as well as continued involvement in 12-step groups.

Again, the patient focused on the development of better coping skills, and participated in mindfulness training, DBT (dialectical behavioral therapy) and CBT (cognitive behavioral therapy) treatment, and continued working on a relapse prevention plan, and was increasingly engaged and active in group sessions. His family was supportive of his efforts and the patient had the opportunity for family-focused sessions with regard to discharge planning that occurred a step down to PHP (partial hospital program) level care and IOP (intensive outpatient program) level care with focus on the need for sober supports and arrangements for step down to lower level care in the community with continued substance use disorder and psychiatric services, and encouragement to participate in recovery groups with the obtainment of a sponsor.

Yes, the Residential Mental Health Treatment Services were medically necessary.

The admission and continued inpatient residential rehabilitation treatment were medically necessary in order to address issues related to relapse with focus on a relapse prevention plan and additional work on developing coping skills in a case that poses high risk for relapse; in order to address co-morbid psychiatric disorders with medication and evidence-based therapy; in order to address the patient's lack of awareness of the seriousness of his illness with psycho-education and evidence-based psychosocial interventions; in order to address the social environment including use of multiple substances of use with high risk for relapse; and in order to work on coping skills that will be necessary in building an effective sober support system and continued recovery efforts with community providers while maintaining his abstinence with peer supported recovery groups. None of this therapeutic work could have been safely or effectively provided at a lower level of care in view of the multiple, complicating factors in this case, the high risk for relapse, the treatment history with relapses and continued use of substances and mood disturbance/disorder and comorbid psychiatric disorders despite access to treatment, and the lack of a reasonable recovery environment that includes high risk behaviors including use of dangerous combinations of substances (alcohol and stimulant medication), and the patient's initial ambivalence towards treatment or lack of commitment to a recovery process, and treatment refractory nature of his bipolar mood disorder complicated with psychotic features.

This answer is consistent with prevailing standards of professional practice and ASAM (American Society of Addiction Medicine) Criteria and scientific literature and published practice guidelines referenced below, and with NY (New York) State instruction for this review including the application of NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria.