Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Abuse/Addicition. 
Treatment: Substance Abuse Inpatient. 

The insurer denied Continued Substance Use Residential Rehabilitation Services. 
The denial was upheld in whole. 

The patient is an adult male who was admitted to a residential rehabilitation substance use disorder facility for treatment of opioid (prescription opiates) and cocaine use disorders. The patient was using prescription opioids together with intermittent use of cocaine. He had longstanding use of substances including past use of benzodiazepines (Valium), Ecstasy (MDMA) and gamma hydroxybutyrate (GBH) with prescription opioids and cocaine as his drugs of choice. His use of substances was causing significant risk to health and impairing his ability to function resulting in job loss. The patient has received substance use disorder treatment in the past including medication assisted treatment with Vivitrol (injectable naltrexone). He had stopped this medication and had relapsed. His addiction psychiatrist had referred him for residential level treatment. The patient has no acute general medical issues though he did report having chronic insomnia. The patient's laboratory assessment and physical examination was normal or unremarkable, and the patient had been medically cleared for substance use disorder treatment at the time of entering treatment. Comprehensive drug screen was consistent with history with positivity for cocaine and prescription opiates. The patient was tobacco dependent with use of less than 14 pack per day. There are no co-occurring psychiatric disorders in this case. The patient denied psychiatric hospitalization or suicidal behavior. The patient has chronic insomnia related to his substance use. Mental status examination revealed a cooperative male with clear speech and linear thought processing that was goal directed. Thought content included no morbid thoughts. Insight was fair with impaired judgment due to the addiction and poor control of impulse to use due to cravings. The patient reported no severe symptoms such as mood disturbances, psychosis, cognitive impairment or perceptual disturbances, or suicidal ideation or aggressive impulses. There were no somatic concerns other than insomnia. The substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions and recovery groups with peer support. He was prescribed comfort medications and vitamins and Remeron and melatonin for insomnia. The patient engaged with rehabilitation treatment and actively participated in individual, group and educational sessions. He received dialectical behavioral therapy (DBT) and participated in 12-step recovery groups with satisfactory progress. The patient was fully engaged in treatment and had made progress with his recovery. In addition to Remeron, he had received naltrexone with plans to resume medication assisted treatment with Vivitrol, as before. He had no complications of his treatment and reported no post-acute withdrawal symptoms other than persistent insomnia successfully treated with Remeron. There were no safety concerns. The patient developed a relapse prevention plan and aftercare plans to include a step down to an intensive outpatient program (IOP), continued involvement with 12-step recovery groups with obtainment of a sponsor, and continued treatment with his addiction psychiatrist with Vivitrol that he had received at the time of discharge. The health plan's determination of medical necessity is upheld. No, the requested health service/treatment of continued residential substance use disorder rehabilitation services is not medically necessary for this patient. The requested residential substance use disorder rehabilitation services was amenable to treatment at a lower level of care. The patient was motivated and capable of effectively continuing in substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure or monitoring of a residential setting in order to effectively participate in rehabilitation substance abuse treatment, or to participate in peer-supported recovery groups or receive other evidence-based treatment such as medication assisted treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the continued residential level services and treatment, as requested. This answer is consistent with prevailing standards of professional practice, American Society of Addiction Medicine (ASAM) Criteria, and the published guidelines and the scientific literature, referenced below, as well as Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, referenced below.