Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for residential substance use disorder treatment from 7/5/16 through 7/15/16. 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 that there is support for the services at issue in this clinical setting. This patient presented with addictive disorders complicated by an anxiety disorder. The placement determination largely falls upon providers working directly with the patient population.  Assisting with this process, the American Psychiatric Association (APA) offers the following guidance on residential placement: Residential treatment is indicated primarily 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. Both the APA Textbook and the American Society of Addiction Medicine echo this sentiment and recommend placement based on a complex, individual assessment. 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. This patient presented with a history of alcoholism that began in mid-adolescence. Her drinking dominated multiple functional domains, impaired her sociability, marriage and relationships, and necessitated emergency services. She minimized her consumption and subsequent mood and anxiety issues. She was unemployed.  She lived alone and had limited social support.  She was unable to sustain sobriety despite an intensive chemical dependency program.  She reportedly drank while in treatment. Three weeks of residential treatment was an insufficient duration of treatment to address the patients relationship with alcohol and mobilize the meaningful therapeutic momentum needed to foster sustained sobriety. The comprehensive services were delivered in accordance with an individual treatment plan.  Further, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  The placement facilitated active treatment, including group therapy, cognitive behavioral therapy, relaxation skills training and family counseling, and set the stage for meaningful aftercare. Finally, the duration of services was consistent with community practice standards. Considering the clinical presentation and the peer-reviewed literature, residential placement was a safe, appropriate disposition consistent with good medical practice. Accordingly, the services at issue were medically necessary for treatment of the patients behavioral health condition. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.