Appeal type: Medical Necessity
Decision: Overturned

The patient is a 50-year-old male with a 35-year history of alcohol abuse. Prior to his admission to substance abuse treatment the patient was drinking on the order of two to three bottles of wine per sitting, typically drinking three to four times per week, in addition to periodic use of marijuana. The latter involved one joint per day, last on 6/1/04, and the submitted notes indicate the patient last drank two bottles of wine, two beers, and three cocktails on 6/22/04 prior to entering residential treatment on 6/25/04. The patient noted a very fractious relationship with his wife; a divorce was soon to be finalized due to his extramarital affairs. In addition, the patient had a history of yelling at his wife and their two children quite a bit and pushed his wife on occasion. His past history was notable for depression, chronic low self-esteem, being self-centered, not listening to and having been dishonest with others, and having suffered demotions at work as well as losing a lot of friends due to his behavior. His depression had been nominally treated in the past five years with Zoloft 100 mg per day.Upon admission to residential treatment, the patient was noted as somewhat hypertensive though otherwise devoid of signs of alcohol withdrawal, and was ultimately diagnosed as having alcohol dependence, marijuana dependence, and probable narcissistic personality disorder. During residential treatment, he was maintained on the Zoloft and was seen in a number of therapies. It was frequently noted the patient was quite angry and intolerant of others. Eventually, he began to look a bit more closely at himself and how this interrelated with the use of alcohol. The patient was felt to have benefited from the program.The patient has requested reimbursement for the substance abuse treatment services he received. The Health Plan has determined the services at issue were not medically necessary.Upon review of the submitted clinical information there appears to be more than enough evidence to establish alcohol dependence, and not merely abuse, in this patient. Specifically, he had been drinking an enormous amount weekly for years on end, with no reprieve. That his last bout of drinking was three days prior to admission by no means ifies the notion of dependence. Rather, this is in keeping with his usual frequency of drinking. What is missing in his history, however, is any particular sustained period of sobriety for the past 35 years. Hence, it appears his cumulative consumption of alcohol is not only the result of abuse per se, but rather, longstanding dependence. That noted, in considering the patients personality structure (doubtlessly narcissistic) he appears to have had little in the way of internal resources to buffer unpleasant affects in general. An intensive outpatient or partial program might be effective for someone with significantly less personality pathology; however, given the patients narcissism, his all too frequent rage bodes heavily for recurrent alcohol use were he to have access to it. A structured, residential setting, however, preempts access to alcohol as well as provides a contained environment where the patient is forced to more closely examine his behavior and how this correlates with his substance use. All told, there is sufficient evidence to point to the patients alcohol dependence, in conjunction with a narcissistic personality disorder, for which residential treatment was medically indicated. Therefore, I have determined that the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.