Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential mental health and substance use treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient was diagnosed with alcohol use disorder severe.  She presented for detoxification in withdrawals with a clinical institute withdrawal assessment (CIWA) for alcohol of 21. Due to her CIWA score, she was placed on a Valium taper.  The patient reported that she drank four bottles of wine a day and has a history of drinking liquor, nail polish remover, and vodka with wine.  She binge drinks every three to four months then she would get sober and attend meetings and groups for up to 50 days, then she relapses.  She was drinking daily for the month prior to admission. The patient reported that she started drinking alcohol at age 11. She has a history of eating disorder and pancreatitis, and was treated in the past with interferon.  She indicated that she was treated for liver disease but the submitted records provided no details. Her liver function tests (LFT) were mildly elevated with her aspartate aminotransferase score at 76 and her alanine aminotransferase score at 56. Prior treatments include three detoxifications, an intensive outpatient program of 90 days, in which she continued drinking, and had an Alcoholics Anonymous sponsor. She reported that her longest period of sobriety was nine months, and her drinking had worsened since 2011. She has a history of blackouts starting at age 35 but she had no seizures or delirium tremens. She worked as a temporary worker and said she drank when she was not working. She had tremors, anxiety, memory problems, and difficulty tracking during conversations.  She reported some depression and affect was flat.  The patient reported that her provider prescribed Ativan and trazodone.  She indicated that she has a history of sexual and physically abuse.  She has a history of suicide attempts, the last being six months prior.  She denied suicidal or homicidal ideation.  She had no significant post-acute withdrawal symptoms.  An antidepressant was under consideration.  She was on gabapentin and trazodone, and Naltrexone and an antidepressant were being considered.  Her vital signs were stable and she was sleeping well.  She participated in her treatment plan, worked on relapse prevention, and had a sponsor. The patient has requested reimbursement for residential mental health and substance use treatment. The Health Plan denied reimbursement noting that the services at issue were not medically necessary for treatment of this patients medical condition. This denial is the subject of this appeal and determination. There is sufficient support for the services at issue in this clinical setting. The patient had some post-acute withdrawals of tremors and anxiety.  She was not a threat to herself or to others, and she was not gravely disabled.  However, cognitively, she showed impairment in memory and difficulty in tracking conversations.  Her history suggests a high risk for relapse. She was brought back, after discharge, by her husband, who indicated that she would drink again. She has had only one period of extended sobriety of nine months. The records indicated that her drinking had worsened in the last five years, and in the month prior to admission, her drinking had escalated to daily. She imbibed an extremely high amount of alcohol (e.g. four bottles of wine) at a time and had blackouts. She had no sober support.  The records noted that the patients husband was physically abusive. Her husband also stated that she could not return home. She endorsed depression and her provider considered starting her on an antidepressant as well as Naltrexone. She was engaged in her treatment and endorsed motivation. She was psychiatrically and medically stable to the extent that her care could have been rendered on an ambulatory basis. However, this patient required the structure of a residential setting to work on relapse prevention and to develop coping skills. The documentation indicates that this patient appeared to have very little impulse control. Therefore, residential mental health and substance use treatment was medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.