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

The patient is a 20-year-old male with a six-year history of polysubstance abuse, chiefly involving marijuana, with more minor use of cocaine. He was referred to residential treatment in March 2006 due to perceived recalcitrance in his use of the drug as well as his refusal to consistently pursue outpatient treatment. The patient had a more remote history of ADHD though this was not felt particularly etiologic in either his use or referral to residential treatment.  He was treated with Adderall XR 30 mg a day for the ADHD.  Review of the treatment notes for his stay from March 2006 through April 2006 point to the patient as being rather resistant to the idea of having a genuine problem with drug use. He estimated smoking a 14 ounce of marijuana per day for the past three years. A pointed note from his father speaks to the extent of the patient having withdrawn from his friends and school for the sake of dealing and using marijuana, as well as having lied about attending outpatient programs.  As such, the father felt it important to remove the patient entirely from the environment to which he was accustomed in order to finally instill sobriety and a different perspective on his drug use.  While in residential treatment, the patient himself cited loving three things, money, marijuana, and being in control.  He also spent a great deal of time on the phone with his girlfriend, who also smokes marijuana, though she indicated that she would no longer smoke when around him.  At the same time, the patient was of the belief that while he may be an addict, he could control the rest of his life and that the path to recovery was the one that he was going to pursue, i.e., regardless of external recommendation.  Overall, he was seen as fairly resistant to the process of recovery and declined placement in a halfway house post-residential care.  His prognosis was felt to be fair to moderate if he followed the continuing care recommendations including limiting contact with his girlfriend.At issue is whether the residential treatment services provided from March 2006 through April 2006 were medically necessary for treatment of the patients condition.Given that the average quantity of a marijuana joint is about .0014 ounces, this would place the patients consumption at about 18 joints per day, which is truly a staggering amount.  That he was so minimizing of his addiction in the face of this speaks to both his denial as well as his narcissism, and was certainly consistent with the amount of dismissal he showed while in treatment.  The comment of one of the patients therapists about the patient wanting to pursue the path to recovery that he was going to do is all too telling in this regard.  It should also be noted that the patient had been referred to outpatient programs prior to residential placement, but simply would not attend them.  All told, it can be concluded that the patient was severely cannabis dependent, not merely abusing it, and warranted much more intensive services than were available via outpatient treatment. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.