Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Dependence, Uncomplicated. 
Treatment: Residential Substance Use Disorders Treatment. 

The insurer denied the residential substance use disorders treatment. 
The health plan's determination is overturned. 

The patient is a male who presented for admission to residential substance use disorder rehabilitation treatment to address his severe alcohol use disorder. The patient was not using other substances of abuse. His presentation was prompted by an intervention by his spouse. 

The patient also presented with serious psychosocial consequences including strained relations with his wife. He had no past history of withdrawal seizures, delirium tremens, or severe withdrawal symptoms, but did report frequent blackouts in the context of alcohol use. He had longstanding co-occurring mood and anxiety disorders best characterized as an unspecified depressive disorder and anxiety disorder treated with Wellbutrin and Lexapro. As noted, he had a decline in functioning related to the alcohol use. There was no history of suicidal behavior or psychiatric hospitalization. 

The evaluation on admission revealed a mental status examination that was free of severe psychiatric symptoms such as psychosis, severe cognitive impairment, or perceptual disturbance. He was anxious and cooperative and superficially motivated for treatment in the contemplative stage of change. He displayed mood disturbance with affective lability, as well as hopelessness, shame and guilt. He had fluent speech and circumstantial and tangential thought processing that was goal directed. He had no aggressive impulses. He reported sleep disturbance. He had support from his family. His insight and judgment were characterized as limited and impaired with poor control of impulses. 

The patient had no acute general medical conditions. He was medically screened and had elevated blood pressure, elevated liver functions and mild withdrawal symptoms per the Clinical Institute Withdrawal Assessment (CIWA). 

The patient is married and college educated and employed and is living with his wife. Stressors included primary support and social environment domains, as well as other psychosocial stressors associated with the alcohol use disorder and health concerns. 

The patient received residential rehabilitation treatment that included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with recovery groups as well as sessions with motivational techniques. The patient engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program. During the residential stay, the patient had a brief period of detoxification treatment with Librium. He initially struggled to engage with treatment due to his affective disturbance/anxiety and insomnia, as well as mild withdrawal symptoms that gradually resolved. He was prescribed vitamin replacement therapy and continued use of prescribed medications, as well as comfort meds and use of Trazodone and melatonin for insomnia/sleep and as needed (prn) use of Propranolol for anxiety. 

The patient engaged with the rehabilitation program with full participation and became increasingly motivated, gaining insight and additional knowledge of a recovery process. The patient was considered at high risk for relapse and lacking coping skills; the risk diminished near the time of discharge though he continued to need work on identification of triggers and treatment of the co-occurring anxiety and depression. 

The need for a disposition with sober supports and family-focused therapy to address the issues within the family constellation are other factors that support the necessity for continued residential level services and the requested benefit through discharge.