Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Substance Abuse: Residential/04/15/2022 forward
The health plan denied the requested residential treatment- substance use disorder services as not medically necessary. 
The health plan's determination is overturned.

The patient is a male who was referred for residential substance use disorder treatment to address polysubstance use and co-occurring psychiatric disorders in the context of impairment of functioning and bouts of psychosis. The patient has a history of polysubstance abuse beginning in late adolescence with the use of multiple substances of abuse. The patient was referred for residential level services after spending days in an acute inpatient setting with treatment of the delusional disorder including the use of Invega Sustena.
The patient has history of multiple psychiatric hospitalizations for psychosis in the context of polysubstance use and ongoing treatment for generalized anxiety disorder with elements of social anxiety and panic attacks and a history of attention deficit hyperactivity disorder (ADHD). There is no history of suicidality or self-harm.
The substance use disorder progressed with a dramatic decline in functioning that was related to the severe substance use disorder and perpetuated by the psychiatric comorbidities and the episodes of psychosis diagnosed as a delusional disorder. Despite treatment efforts in the community and the effort by his 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. Thus, the referral for treatment was prompted by the failure to remain sober despite the availability of treatment in the community and the co-occurring psychiatric disorders.

From the date of admission forward, the patient engaged in treatment with intensive services, sober housing, monitoring and structure provided within the residential treatment program and therapeutic milieu. He was not well motivated initially due to the maladaptive coping and the addictions. He was cooperative and did participate in the rehabilitation treatment with plans to continue with a clinically appropriate step down to include continued medication management, counseling and involvement in 12-step recovery groups. Case summary and group notes indicate that the patient made steady improvement while in treatment and remained abstinent from substances of abuse though had to be directed to complete assignments together with ongoing psychiatric management of the co-occurring delusional and anxiety disorders.

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

Yes, the requested health service/treatment of residential treatment- substance use disorder services, was medically necessary for this patient.
The clinical features and treatment dimensions in this case warranted residential structure and monitoring while providing intensive treatment for the co-occurring substance-related and psychiatric disorders. The patient could not have been safely or effectively treated in a less restrictive treatment setting.

The requested admission and continued Residential Mental Health Treatment was medically necessary in order to address the immediate needs for rehabilitation of severe substance use disorders and to work toward relapse prevention; in order to address the patient's lack of awareness of the seriousness of his illnesses with psycho-education and evidence-based psychosocial interventions; and in order to address issues within the social environment, especially in working with the patient's family with whom he lived and in order to work on coping skills that will be necessary in building a sober support system and continued recovery efforts with community providers and engagement with age-appropriate 12-step recovery groups, and, services to address the psychotic and anxiety disorders.