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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services received for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue for this patient. The American Society of Addiction Medicine recommends placement based on a complex, individual, clinical assessment rather than reimbursement limitations, program ideology, or utilization reviewers, while the American Psychiatric Association recommend residential treatment for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Additionally, the practice guideline jointly authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases:  There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment.  It is more than likely that chronic medical and psychiatric comorbidities would demand greater clinical attention in the absence of sustained sobriety for a patient such as this.  In this patients case, he had not consolidated the treatment gains necessary to succeed in the outpatient setting and promptly would have relapsed in a community-based setting if discharged that day.  He was anxious and having severe cravings to drink. He was started on clonidine and naltrexone, respectively. He was depressed and anxious, and still craving alcohol.  He was emotionally exhausted.  He viewed his family as unsupportive.  He was not speaking with his spouse.   However, he was appreciative of the treatment setting and working his program with the help of a sponsor.  Thereafter, the records indicate that the patient was actively engaged in treatment until the day of discharge.  The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting. The records indicate that the patients alcoholism was impairing his daily routine and contributed to significant impairment across multiple domains of functionality.  He reported a family history and an early age of first use, both of which are associated with more severe cases of alcoholism. His drinking was causing health problems, straining his marriage and jeopardizing his employment. His motivation was undermined by reports of his spouses excessive alcohol consumption. The patient also had co-occurring depression, hypertension, and hyperlipidemia. The records also document elevated liver enzymes, conditions that were more than likely impacted by his alcoholism. Finally, despite completion of an outpatient treatment program and attendance at community meetings, the patient was unable to maintain sobriety in his environment.  Additionally, the services at issue provided at the time were reasonably expected to improve his condition and prevent a more serious episode of illness. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.