Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Alcohol abuse/addiction
Treatment:  Substance Abuse Treatment: Residential

The patient presented for substance use disorder residential rehabilitation treatment to continue to address substance use of stimulants (cocaine), cannabis (marijuana), and alcohol.  The patient had no past history of withdrawal seizures, delirium tremens or severe withdrawal symptoms.  He had a history of substance use disorder with onset at preadolescent age with alcohol and marijuana, escalating to daily continuous use with subsequent use of cocaine at his late twenties.  His substance use had resulted in psycho-social problems including estrangement from the mother of his son and loss of employment.  The patient had previously engaged in substance use disorder treatment with a chronic relapsing clinical course.  There was no current history of psychiatric disorder or treatment though he had a history of depression in adolescence.  The rehabilitation treatment included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and, involvement with 12-step recovery groups.  The patient engaged in treatment and intensive services, sober housing, monitoring, and structure provided within the inpatient residential treatment program.  The patient participated actively with treatment, and showed no significant symptoms or signs of withdrawal, and had no complications of rehabilitation treatment.  The patient participated in therapy.  The patient was noted to be engaged in treatment with no biomedical or psychiatric issues.  He was actively participating in treatment with treatment plans to address coping skills and to develop sober supports.  He also had the goal of re-connecting with his son and gaining employment.  The patient had completed 35 days of treatment to include ongoing therapy sessions.  He had no complications during this time interval, and had urine drug screens that were negative.  He was actively engaged in therapy sessions and residential level-of-care without incident.  Issue under review is for ongoing Behavioral Therapy; the plan previously approved 35 days.  The health plan's determination of medical necessity is upheld in whole.  The health plan in its determination of medical necessity, has acted reasonably with sound medical judgment and in the best interest of the patient.  The patient was motivated to actively engage in rehabilitation treatment without biomedical complications or significant withdrawal symptoms.  He had prior exposure to substance use disorder treatment and was able to engage and participate actively in the treatment plan without complication.  There were no psychiatric disturbance or general medical concerns that required inpatient level services, structure or monitoring.  The patient was noted to benefit in all aspects of his treatment plan throughout his continued stay.  He had a supportive family and access to sober housing from which substance use disorder treatment could be received.  The patient had access to additional supports including sober housing and/or sober supports from his home, and other supportive services in the community, including peer support through 12-step recovery groups such as Alcoholics Anonymous (AA) and/or Narcotics Anonymous (NA).  Thus, the patient's Behavioral Therapy together with rehabilitation services could have been effectively provided at a lower level of care.