Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old male who was admitted to residential treatment in October 2005, ostensibly for treatment of alcohol abuse. Admission diagnoses included alcohol dependence, major depression, post-traumatic stress disorder (PTSD), and myofacial pain. The patient had been involved in an airplane incident in which he sustained injuries following extreme turbulence while flying to Brazil in 1993 on a work assignment, resulting in a number of injuries to his jaw, back, and knees. Subsequently, and following a number of restorative surgeries to his jaw, he experienced very severe pain in his back and legs as well as severe headaches. In part, this led to his discontinuing work, thereafter reliant on his wife. However, the patient had also recently finalized a divorce from his wife and had increased his drinking in the past 8 months thereafter, on the order of one to two six-packs of beer per day. Despite a remote history of polysubstance use, he was not using any drugs prior to admission. Prior to the most recent residential placement, he had spent about three days at a prior treatment facility and had been abstinent from alcohol for about a week.  Review of the submitted progress notes indicates the patient was depressed, but also rather angry and not infrequently entitled.  Despite a number of antidepressants that were offered (including Lexapro and Wellbutrin), he quickly claimed that he was unable to tolerate them and they were discontinued. A brief trial of Zyprexa was equally fraught with difficulty, and hence also discontinued within days. The patient felt the only tolerable medication was a stimulant such as Ritalin, though this had not been prescribed. By November 2005 he refused Zyprexa, Lexapro and Wellbutrin, and all were discontinued. The submitted records note the patient as angry, entitled, demanding, irrational, and drug seeking. In November 2005 it was believed the patient was likely to leave treatment shortly because the staff was not acceding to his demands. By and large, the patient was noted as very focused on his pain medications and not particularly on his depression. There is no documentation about symptoms of withdrawal from alcohol or anything pertaining to alcohol cravings.  At issue is whether the residential treatment services were medically necessary for treatment of the patients condition.There is no question that the patient suffers from chronic pain and depression, the former likely worsened by the depression, and that treatment for both is indicated. However, admission to residential treatment was predicated on substance abuse, namely alcohol abuse. There is no documentation of prior attempts at treatment on an outpatient basis.  Similarly, there is no documentation of any alcohol-related symptoms or signs as of the patients admission. Rather, there is a plethora of documentation about his severe pain, anger, and entitlement. The patient ultimately left treatment prematurely. Given the brevity of his treatment with a variety of antidepressants, this could have been approached equally well on an outpatient basis. All told, there is no evidence to indicate the patient was not appropriate for treatment on an outpatient basis. Accordingly, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.