Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 20-year-old female enrollee has requested reimbursement for residential treatment center services provided from 11/5/16 through 11/23/16. 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 the residential treatment center services provided from 11/5/16 through 11/23/16 were medically necessary for treatment of the patients medical condition. 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. In this case, the patients alcoholism and benzodiazepine dependence were impairing her daily routine and contributing to significant impairment across multiple domains of functionality. She reported an early age of first use, which is associated with more severe cases of alcoholism and poorer outcomes. She reported to drinking up to five alcoholic beverages daily and consuming up to 60 mg per week of alprazolam and 75 mg of zolpidem. She experienced family strain and interpersonal discord due to her substance use. Further, the patient had co-occurring depression, anxiety and thyroid disease. Her mental illness was treated with a complex regimen including a mood stabilizer, second generation atypical antipsychotic, dual-acting serotonergic and noradrenergic enhancing medication, and a sedating antidepressant. Additionally, the patients home environment was not supportive to recovery and she had no sober peer support network. She had been treated at various levels of care but had been unable to maintain sobriety in the outpatient setting. On 11/3/16, there was concern of an eating disorder. On 11/4/16, there was further discussion of her affective illness with consideration given to the bipolar spectrum. She was not sleeping well and trazodone was prescribed. Levothyroxine was started that day as well. Additionally, the patient had not completed the family program, which was set for the following week, while lithium was increased on 11/21/16 for persistent irritability. In sum, the record suggests that the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting as of 11/5/16. Further, the patient remained engaged in active treatment during the entire admission, which also served to help clarify the diagnostic assessment, engage family in the therapeutic process and arrange appropriate aftercare. Based on the relevant history, severity of the addictive disease and concerning psychiatric comorbidity, effective treatment could not have been safely and adequately delivered in a setting less restrictive than the residential level of care at the time. The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided at the time were reasonably expected to improve her condition and prevent a more serious episode of illness. Considering the clinical presentation and perusal of the relevant peer-reviewed literature, the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.