Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Residential substance use treatment
The insurer denied the Residential substance use treatment.
The determination is overturned in part.

The patient was referred and admitted for residential level mental health and substance use disorder treatment to address a recurrent mood disturbance diagnosed as unspecified bipolar disorder with comorbid unspecified anxiety disorder in the context of substance use disorders with regular use of cannabis and alcohol. Prior to admission, the patient had received emergency medical services for alcohol poisoning and recently had required emergency services for running away with a facial injury and subsequent involvement of the child protective services (CPS). The patient's substance use had started in early adolescence and escalated with progression of the disease including frequent blackouts and affective instability with anger and persistent irritability resulting in behavioral disturbance and conflict with her adoptive mother.

The patient has a history of substance use disorder treatment episodes without sustained benefit, as well as escalating bouts of aggression/irritability with relationship problems with peers at school and her mother with whom she lived. The patient has had ongoing issues with family related to problematic and disruptive behavior, and ongoing use of substances despite having treatment in the community. The patient's symptoms of mood and anxiety disorders remained despite multiple medication trials and outpatient treatment with decline in social, family, and educational functioning resulting in the referral for residential level services and treatment.

The mental status examination at the time of admission for residential treatment was free of severe psychiatric symptoms such as psychosis, mania, thought disorder, severe cognitive impairment or perceptual disturbance (hallucinations). She was anxious with dysphoric affect and persistent irritability. She also presented with coping difficulties with peers and family, and was described as having limited insight, impaired judgment and poor impulse control. Additionally, she presented as fidgety, distractible with poor concentration and prominent sleep disturbance. The patient had no acute general medical conditions, or drug or alcohol withdrawal symptoms. She is tobacco dependent.
The patient is single and a student. She had significant stressors related to oppositional behaviors as well as irritability and affective instability. 
The patient underwent a comprehensive psychiatric evaluation with plans for safety monitoring and treatment planning that included therapeutic interventions to improve coping skills and address core symptoms of mood disorder together with interventions to address the substance use disorders with her primary drugs of choice as alcohol, as well as frequent use cannabis and tobacco. The treatment plan included the goals of improved coping; breaking the cycle of self-destructive behaviors; and the development of healthy relationships. Individual, group and family therapies were provided, as clinically appropriate. She also had the opportunity to participate in age-appropriate groups with peer support. The program focuses on organizational skills; self-care; peer relationships; and life skills as well as behavioral and emotional regulation with stress management, behavioral techniques and evidence-based therapy including medication management and focus on family functioning. The patient also received ongoing educational programming with assignments and vocational services pertaining to educational needs.
The patient actively participated in the treatment plan and worked on therapeutic-recreational, neurodevelopmental, social, and emotional functions in the context of a residential program with 24-hour monitoring, structure, intensive treatment, and social supports. She continued to receive residential services with revisions of the treatment plan and clinically appropriate titration of her medications that included Seroquel, Cymbalta, gabapentin and Wellbutrin at therapeutic dosages.
The treatment course and case records/notes reflect a stormy course during the first six weeks of treatment with continued evidence of mood swings, irritability and disruptive behavior including conflict with peers and her mother. She made slow and uneven gains with several incidents involving female peers and her mother during therapeutic leaves and family-focused sessions. She displayed mood swings and conflict with relationship functioning requiring staff re-direction and the implementation of cognitive behavioral therapy (CBT). Nonetheless, the patient demonstrated increasing engagement with the treatment plan and no active oppositional or violent behavior, and abstinence from substances of abuse while in treatment.
She made steady progress that slowly resulted in stabilization of mood with titration of her medications that were at therapeutic or near-therapeutic dosages. She did continue to display persistent irritability, insomnia and bouts of affective instability that had resulted in an increase in her dose of Seroquel and the addition of Wellbutrin to address problems with mood and concentration including consideration of a diagnosis of Attention Deficit Disorder (ADD). Again, during the course of treatment prior to discharge, the patient had intermittent bouts of affective instability and ongoing relational problems consistent with history. However, she was using her coping skills and maintaining better impulse control. She was actively working on family issues especially with regard to the continued risk for boundary problems. She was completing assignments and was maintaining abstinence from substances of abuse. Therapeutic interventions were continued with appropriate monitoring to include continued family work and medication management and consideration of a safe and clinically appropriate disposition.

The issue under review is the medical necessity of Residential Mental Health Treatment.

The requested health service/treatment of residential substance use treatment was medically necessary for this patient, in part.

The patient continued to display clinical features and symptoms that necessitated residential level services as she struggled to engage in treatment and had intermittent bouts of affective instability with lack of emotional control that did require residential level structure and monitoring with active treatment. She had a history of treatment failure with lower level services and had recently displayed significant oppositional behavior with maladaptive coping, emotional regulation problems, distress problems, interpersonal functioning problems and day-to-day functioning problems that included combative behavior. She continued to represent a safety risk and could not have been effectively managed in a less restrictive treatment environment.
However, after 18 days, the patient was noted to be engaged in treatment with improved functioning, diminished levels of anxiety, and more appropriate behavior, as noted in the clinical summary. Therefore, the residual symptoms of mood and anxiety disorders and co-occurring substance use disorders; and problems with psychosocial, educational and daily functioning were amenable to treatment in a less restrictive environment  and the monitoring, structure and intensity of residential services were no longer medically necessary, as indicated by improved mental status and functioning and engagement in the treatment plan. In summary,  the patient's treatment could have been safely and effectively provided with lower level services in a less restrictive treatment environment, as noted in the answer to question 1 above. The patient's psychosocial stressors were not so severe to prevent ongoing assessment and treatment at a lower level of care in this case scenario. Moreover, there were no general medical issues, no co-occurring substance use disorder treatment issues, and no other clinical features that would have warranted continued residential level treatment.
This answer is consistent with prevailing standards of medical practice and the guidelines and scientific literature referenced below, and in keeping with American Society of Addiction Medicine (ASAM) Criteria and with the application of NY State OASAS LOCADTR 3.0 Criteria, also referenced below.