Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Substance Abuse Residential Treatment. 

The insurer denied substance abuse residential treatment. 
The determination is upheld. 

The patient was admitted to residential level services for treatment of severe cannabis use disorder. The patient has a history of escalating use with up to twelve grams of marijuana at most. The patient reported no history of withdrawal seizures or blackouts or severe withdrawal such as hyperemesis; he did not report erratic behavior or high-risk behaviors such as driving under the influence. The patient has one prior substance use disorder treatment. 

The patient presented with a comorbid psychiatric disorder diagnosed as unspecified anxiety disorder, but no history of psychiatric hospitalization, and no history of suicidal or self-harming behaviors. He has good social supports from family. 

On mental status examination, he was groomed and cooperative with anxious demeanor and good eye contact. He exhibited apprehension, nervousness, tension and worry. His mood was euthymic. He endorsed bouts of boredom that served to trigger his substance use. There was no evidence of mania, thought disorder, psychosis, perceptual disturbance or severe cognitive impairment though he did have concentration and attention problems. Insight and judgment were fair. He was judged to be in the contemplative stage of change. 

There were no acute general medical issues in this case. The patient's medical screening revealed a drug screen consistent with history but no other abnormalities. He has a history of asthma with a rescue inhaler. 

The patient was admitted for residential level rehabilitation treatment of the comorbid substance use disorders and co-occurring psychiatric disorder. The rehabilitation program provided for comprehensive treatment that included focus on coping skills, plans for the development of a relapse prevention plan with identification of triggers, education about the disease model of addiction, and involvement with groups and individual therapy, as well as family focused sessions and involvement in recovery groups and other therapeutic activities to improve coping skills and develop sober supports. 

The patient engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program. Psychiatric evaluation was provided with use of Lexapro, Buspar and as needed (prn) Vistaril to address the unspecified anxiety symptoms. The patient was participating in treatment without incident or complications with respect to biomedical, general medical, emotional or other treatment domains. The patient was attending groups and completing assignments despite ongoing symptoms of anxiety which had improved. The patient was deemed to be sufficiently motivated for continued treatment with a fair prognosis. There was no evidence for significant withdrawal symptoms or biomedical complications. 
 
The case summary and records, health plan documents, appeal documents, correspondence from the health plan and treatment facility, and, the rationale for the denial of certification for coverage of the requested treatment, were reviewed. The plan medical necessity criteria and guidelines, New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria were reviewed. This review is New York State mandated in consideration of the LOCADTR Criteria/Guidelines. 

At issue is the medical necessity of continued residential substance use disorders treatment. 

The requested health service/treatment of continued stay in the substance use residential rehabilitation treatment setting is not medically necessary for this patient. 

The requested benefit of continued residential mental health stay is not reasonable in this case scenario, as patient is amenable to treatment in a less restrictive environment that addresses both the mental health and co-occurring substance use disorders. The patient has stabilized to the extent that safe and effective treatment could be provided at a lower level of care with intensive services and a safety plan and sober supports. The patient's symptoms of anxiety had improved, and there was no imminent risk of suicide or self-harm in this case, or severe symptoms such as psychosis, mania/mood cycling, perceptual disturbance or thought disorder that would have required residential level services. The patient is engaged in treatment with external and internal motivating factors, cooperative with staff, and medication adherent, and the patient is future oriented with regard to a commitment to a recovery effort. His family is supportive and involved in the treatment planning and treatment. Thus, the proposed continued residential level services did not meet prevailing standards of practice with regard to continued care at the residential level and is not in keeping or consistent with New York State LOCADTR 3 Criteria. Moreover, the denial determination including application of LOCADTR Criteria is appropriate and reasonable in this case scenario. 

The patient no longer required the continued structure and monitoring and intensity of a residential level service. Effective treatment could have been provided at a lower level of care in keeping with prevailing standards of medical practice, American Society of Addiction Medicine (ASAM) Criteria and the scientific literature, referenced below, as well as NY State instruction for this review and the application of NY State OASAS LOCADTR 3.0 Criteria.