Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Generalized Anxiety Disorder (GAD); Cannabis and Xanax use disorders 
Treatment: Psychiatric residential treatment center level of care 

The insurer denied coverage for psychiatric residential treatment center level of care. The denial is reversed. 

This patient is a male who was admitted to residential treatment upon referral. The patient reported using cannabis daily and also using non-prescribed Xanax. The patient reported symptoms of anxiety, including anxious mood, excessive worrying, compulsive dishonesty, impulsive behavior, anger, attention problems, and had poor decision making. The patient's diagnoses included Generalized Anxiety Disorder (GAD) and Attention-Deficit/Hyperactivity Disorder (ADHD) in addition to his diagnoses of Cannabis and Xanax use disorders. The patient attended individual, group, and family therapy, and took Abilify, Sertraline, and Adderall. The patient was discharged. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, this patient was considered in need of 24 hour substance rehabilitation treatment as he was using cannabis and Xanax daily. The patient lacked the insight into the consequences of his substance use and had comorbid psychiatric symptoms that exacerbated his substance use. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as he continued to use cannabis daily and Xanax despite negative consequences, including school suspensions for use in school. The patient also reportedly was vaping cannabis oil. Also, the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that the best treatment outcomes occur with longer durations of treatment. It also states that recovery from drug addiction is a long term process and that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. In this case, this patient was at high risk to continue use cannabis and Xanax. Thus, psychiatric residential treatment setting was medical necessary to help this patient develop the necessary skills for abstinence. 

Notes dated reported that the patient was still struggling with telling the truth, was lying, had anxiety, and needed to work on assertive communication. Notes reported that the patient needed to better manage his anxiety, ADHD, and obsessive compulsive symptoms. Notes reported that the patient desired to continue using substances even when he returned home so the patient was not ready for discharge out of this residential setting to prevent early relapse. Notes reported that the patient had difficulty with understanding consequences to substance use. The patient needed more time to increase his understanding regarding substance use and gain skills to abstain and avoid relapse, decrease anxiety, improve coping skills, improve communication, and interpersonal relations. Notes reported that the patient still struggled with honesty though he was working on it. The patient was discharged with the recommendation for frequent random drug tests. 

Based on this review of the medical record and the literature, psychiatric residential treatment center level of care was medically necessary to treat this patient's medical condition. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the psychiatric residential treatment center level of care should be reversed. The medical necessity is substantiated.