Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for substance use residential performed from 4/5/17 through 4/29/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. The American Society of Addiction Medicine recommends placement based on a complex, individual, and clinical assessment. While the American Psychiatric Association recommends residential treatment for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Additionally, the practice guideline jointly authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases:  There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment.  In this case, the records note that the patients abuse of alcohol was impairing her daily routine and contributing to significant impairment across multiple domains of functionality. The documentation indicate that she experienced recent stress over her divorce and the sale of her home. However, the patients co-morbid anxiety and depression were mild and she did not receive specialty treatment previously. She did not have a psychiatric condition or medical illness that required treatment at the residential level of care.  Further, the patient was motivated for recovery.  She was employed and had safe housing and good family support. On 4/4/17 and 4/5/17, the patient still evidenced significant withdrawal symptoms on a validated rating scale.  By 4/6/17, she was noted to be interacting positively with no anxiety. The following day she was considering intensive outpatient programming as an aftercare option.  On 4/10/17, the patient was psychiatrically stable. The psychiatrist extended clonidine for protracted withdrawal symptoms, but the patient only took the medication one time thereafter.  On 4/12/17, the patient was self-administering medications.  She denied any cravings.  On 4/13/17, despite being reminded earlier in the day, the patient did not attend her therapy session.  On 4/14/17, the patient was optimistic and smiling.  She was sleeping well at night.  Her anxiety was low, and she denied any craving or depression.  Of note, the patient had no history of chemical dependency treatment such as sponsored community programming, outpatient counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment.  In sum, the patient had improved with the treatment intervention.  By 4/14/17, she was autonomous and maintaining motivation for sobriety.  Further, she had not failed a less restrictive treatment course during the episode of illness.  As such, the residential treatment center services from 4/5/17 through 4/14/17 were medically necessary, but not thereafter. 
Therefore, for the reasons stated above, a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be partially overturned.