Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction
Treatment: Substance Abuse: Residential
The health plan denied the requested residential stay as not medically necessary. 
The health plan's determination is overturned.

The patient is an emerging adult male referred for residential substance use disorder treatment to address poly-substance use and co-occurring psychiatric disorders in the context of impairment of functioning and severe psychosocial stressors. The patient has a history of mood and anxiety disorders and attention deficit hyperactivity disorder (ADHD) with co-occurring poly-substance abuse beginning in adolescence with use of multiple substances of abuse including cannabis, anxiolytics (benzodiazepines), and stimulants (amphetamines) with the latter two classes of substances as drugs of choice. The patient was referred for residential level services with the threat of eviction from the family home due to continued escalating use of substances.
The patient has history of psychiatric hospitalization (seven-day inpatient stay) and suicidal ideation in the context of ongoing treatment for major depressive disorder of moderate severity, social anxiety, and ADHD. He was abusing or misusing prescribed Clonazepam and Etizolam, and was using amphetamines including 4-FMPH, a methylphenidate analogue.
The substance use disorder progressed with a dramatic decline in functioning that was related to the severe substance use disorders and perpetuated by the psychiatric comorbidities. Despite treatment efforts in the community and the effort by parents to address the mental health and substance use disorders, the patient remained resistant to treatment resulting in the subsequent referral for residential level treatment under threat of eviction from his parent's home. Thus, his referral for treatment was prompted by the failure to remain sober despite treatment in the community and the co-occurring psychiatric disorders, as well as parent child relational problems or conflict.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of Residential substance use treatment is medically necessary for this patient.
The patient's lack of awareness or limitations of insight together with the seriousness of his depressive and anxiety disorders and co-occurring substance use disorders is illustrated by his continued risk for suicide in view of the past history of suicidal ideation and psychiatric hospitalization; and, in view of the continued use of high-risk substances of abuse including designer stimulants together with benzodiazepines with blackouts and functional decline despite having access to treatment in the community, and despite having sober support from the family, and in the context of parent-child relational problems with the threat of homelessness. The presence of high-risk behaviors does complicate this case to a great extent, as does the negative influence of peers or the social environment. Additionally, the patient had serious mental health issues (along with the family stress) that were triggering the patient's use of substances and were associated with a relapsing course. These factors are the reason that the patient could not have been/could not be safely or effectively treated at a lower level of care during the time interval under review. 
None of this therapeutic work could have been safely or effectively provided at a lower level of care in view of the multiple, complicating factors in this case for the time interval under review, and in view of the treatment history and history of treatment failure with lower levels of care and/or brief inpatient services.