Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse: Residential. 
The insurer denied residential substance abuse for medical necessity. 
The denial was overturned.

The patient is an adolescent male who underwent inpatient detoxification treatment and was referred and admitted for residential substance use disorder in order to address poly-substance use disorder with cannabis, sedative-hypnotic-anxiolytic (benzodiazepine/Xanax) and stimulant (cocaine) class substances. He had complications of the substance use requiring hospitalizations together with a decline in functioning and family distress. He had received treatment in the community and had failed to achieve sobriety, and was using while in treatment. 
Evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms such as mania, thought disorder, psychosis, or perceptual disturbance. He was not clearly motivated for rehabilitation treatment but had support from his parents. The patient was described as having limited insight due to the addiction together with questionable judgment and poor control of impulses. He had experienced and reported symptoms of anxiety and insomnia together with dysphoria related to family discord. His peers were using substances of abuse, and he was deemed to be at high risk for relapse.
The patient reluctantly engaged in treatment with intensive services, sober housing, monitoring, and structure provided. While in residential treatment, progress toward treatment goals was slow due to the patient's ambivalence towards treatment and lack of insight and motivation. He received group, individual and educational sessions together with work to develop life skills and involvement in peer-supported recovery groups.
At the time of discharge and step down to lower-level care, the patient had developed better coping skills and a relapse prevention plan. He was discharged.
At issue is the Residential Substance Use Treatment for medical necessity.
The health plan's determination of medical necessity is overturned in whole.
The patient's admission and continued residential level treatment through discharge was reasonable and in the best interest of the patient. He continued to display clinical features and symptoms that necessitated the admission and the continued residential level services, as he struggled to engage in treatment and required residential level structure and monitoring with active treatment. The patient has a history of treatment failure with lower-level services and had recently displayed significant problematic behaviors with maladaptive coping, and interpersonal functioning problems within the family constellation. He continued to represent a safety risk and high relapse risk. The monitoring, structure and intensity of residential services was medically necessary.
This is consistent with New York State instruction for medical necessity, including the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines.
Therefore, the requested health service/treatment of Residential Substance Use Treatment was medically necessary for this patient.