Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol use disorder. 
Treatment: Residential Substance Use Disorder Services. 

The insurer denied the Residential Substance Use Disorder Services. 
The denial is overturned. 

This case involves an adult female, with severe alcohol use disorder who was admitted to residential rehabilitation treatment and who received treatment of co-occurring mental disorders. Her presentation for residential level care was prompted by a relapse after two years of sobriety; her alcohol use quickly escalated to two liters of wine per day with a rapid decline in functioning and inability to maintain work as a nurse. The alcohol disorder had its onset in adolescence with a chronic relapsing course in the context of a co-occurring anxiety disorder best characterized as generalized anxiety disorder, an unspecified depressive disorder, and severe psychosocial stressors within the primary support, social environment and occupational domains. The alcohol use resulted in impairment of functioning with regard to social, occupational and daily functions putting her health and job at risk. The patient had prior past substance use disorder treatment primarily with the use of peer-supported recovery groups and mental health treatment. Her self-referral for treatment was prompted by her supervisor who was supportive of her seeking treatment. 

The patient presented with associated symptoms of anxiety and dysphoric mood in the context of moderately severe post-acute withdrawal symptoms related to the alcohol use. 

The patient began residential level treatment with the structure, monitoring, and the intensity of inpatient level services. Treatment included group, individual, and educational services with the addition of non-pharmacologic interventions to address the anxiety disturbance, and emphasis on coping skills with the goal of the development of a relapse prevention plan and planning for a safe and appropriate discharge back to the community. She was prescribed sertraline and gabapentin at appropriate dosages with vitamin replacement and continued use of as needed (PRN) Vistaril and trazodone and melatonin to address anxiety and insomnia. She had received evidence-base interventions, and the patient's insight and mood improved in response to the treatments, as she was calmer with euthymic mood with persistent reports of anxiety during her stay. 

The patient was more active in her treatment and increasingly engaged in group sessions. Family wellness and other wellness activities were provided together with mindfulness, yoga, meditation and continued medication management with the addition of propranolol to address anxiety. By the last week of treatment, the treatment team was recommending intensive treatment in the community with continued involvement in peer-supported recovery groups and sober supports, and recommendations for the obtainment of a sponsor including a nurse-to-nurse program. Prognosis was guarded to fair and she was deemed to be at high risk for relapse unless continued treatment was to be provided. Discharge planning occurred with discharge and return to the community/home and plans for continued substance use disorder treatment and involvement in recovery groups with sober supports, as well as treatment from her primary care physician  and referral for psychotherapy/mental health services. The patient was not interested in medication assisted treatment and was discharged on sertraline, propranolol and melatonin at clinically appropriate dosages. 

Yes, the proposed treatment was medically necessary for this patient. 

As the appeal from the patient and treatment facility indicated, the residential level treatment was needed and medically necessary in that the patient had no alternative level of care treatment available in the plan network, thus prompting the admission to residential level care after detoxification treatment. Medical necessity is therefore met, as residential level treatment was provided as clinically appropriate with the least restrictive treatment setting and level of care. Moreover, in view of the clinical features in this case that included limited supports (living alone), a decline in functioning putting her and her job at risk (job jeopardy) and the severity of alcohol use; the residential level of care did meet the American Society of Addiction Medicine (ASAM) Criteria contrary to the health plan's denial and determination on the basis of American Society of Addiction Medicine (ASAM) Criteria. 

The residential level of services, structure, and monitoring provided in this case are warranted in view of the severity of the alcohol use disorder and associated symptoms of anxiety and complications of the alcohol disorder. The patient could not have been effectively managed with lower-level services during the time interval under review. 

The residential level services through discharge were clinically appropriate, and consistent with prevailing standards of medical practice. The services were provided with evidence-based treatments that are known to benefit patients with severe alcohol use disorder, as well as providing services to address treatment issues in a patient with moderately severe post-acute withdrawal symptoms and complications of an alcohol disorder that included liver damage, and with high risk for relapse. Thus, the patient's severity of alcohol use disorder and associated symptoms of anxiety, did warrant and necessitate the admission and the continued residential level services, as proposed, with the plan for step down to lower-level services once the patient had stabilized with the ability to achieve abstinence with sober supports in working toward discharge plans and considering a safe and appropriate transition to the community with appropriate aftercare. 

Moreover, the patient presented with high risk for relapse in view of an inadequate recovery environment, a relative lack of coping skills and readiness to change, and a lack of sober supports despite some past exposure to recovery groups. The time spent with motivational techniques and other interventions throughout the residential stay were essential to a successful therapeutic outcome in this case. These clinical features and treatment dimensions did support the necessity for the continued inpatient level services and the continued structure and monitoring and intensity of services provided at the residential level of care through discharge. 

This answer is consistent with the application of the American Society of Addiction Medicine (ASAM) Criteria, and with the published guidelines and the scientific literature, referenced below. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

The residential level treatment was needed and medically necessary; moreover, the patient had no alternative level of care treatment available within the plan network, thus prompting the clinically appropriate admission to residential level care after detoxification treatment. 

This answer is consistent with the application of the American Society of Addiction Medicine (ASAM) Criteria, and with the published guidelines and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews and the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, referenced below.