Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 20-year-old male who has been diagnosed with alcohol use disorder severe, sedative-hypnotic use disorder moderate, attention deficit hyperactivity disorder (ADHD), Aspergers, anxiety, and obsessive compulsive disorder (OCD). The patient endorsed drinking four to five beers with last use on 2/25/18, two glasses of wine daily with last use on 2/24/18, and 8 to 10 ounces of gin, vodka or whiskey once a week, and Valium 20 mg a day for two years with last use on 2/26/18. He also endorsed use of opioids, benzodiazepines, and cannabis. He stated that his longest period of sobriety was six months. Prior treatment included 23 days of treatment for opioids at age 17 with relapse on discharge. He recently had a Ketamine overdose. After release from the hospital he went home and went into respiratory failure. He was admitted to the ICU for six days with hematemesis, etiology unknown. He was admitted on 3/8/18, and was placed on Vistaril, Robaxin, Tylenol, and Prevacid. During the course of his treatment, the patient was cooperative and attended groups but indicated that he could stop drinking based on will power. He did not wish to work on steps or with a sponsor. However, on 4/1/18, he completed step I. He and his parents participated in family week. He would occasionally make statements which would provoke other group members, or look at photographs of alcohol on his phone. At times he was noted to be focused and engaged. On 4/2/18, the patient was oriented in all spheres, he was not suicidal or homicidal, and he was focused and attentive. He indicated he wanted to be discharged and could stop on his own. He denied that he had a pattern of addiction. He expressed shame and guilt over his behavior and the effect it had on his family. His mood was irritable, angry, and anxious with flat affect. On 4/3/18, the patient toured a sober living environment and went to dinner with his father. He demonstrated good motivation and participation. The patient has requested reimbursement for substance abuse residential treatment services provided from 4/2/18 through 4/8/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. The records provided for review do not support the medical necessity of the substance abuse residential treatment services provided from 4/2/18 through 4/8/18 for treatment of this patients medical condition. The patient was not suicidal or homicidal, and he was not violent or aggressive towards others. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. He was medically and psychiatrically stable, and no medications were added during his residential stay. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. Although cooperative, he demonstrated inconsistent participation and engagement. He also showed a level of provocative behavior, stirring up other residents with drug talk and images. He spoke of his intent to resume drinking. He did express shame and guilt, and had some insight into the fact that his behavior had a negative impact upon others. However, the appropriate psychological treatment did not require residential level of care services. The primary factor getting impeding this patients sobriety was himself. Residential level of care was not medically necessary. He could have been safely and effectively treated in an ambulatory setting. Thus, the substance abuse residential treatment services provided from 4/2/18 through 4/8/18 were not medically necessary.  Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.