Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorder
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The case involves a male who was admitted to inpatient rehabilitation and substance use disorder treatment beginning to address substance use disorder with opioid, alcohol and stimulant class substances. The patient has no history of withdrawal seizures or delirium tremens, but did report blackouts. He was receiving medication assisted treatment with methadone 50 milligrams daily. He had been using up to five bags of heroin and cocaine with intravenous (IV) administration, and using up to three pints of liquor per day, as well as taking his methadone prescribed from a methadone maintenance treatment program (MMTP). His drug screen was positive for cocaine, opiates, Fentanyl and methadone.

The patient has a history of psychiatric disorder best characterized as schizoaffective disorder, bipolar type; he denied history of suicidal behavior and had been lost to follow up with his mental health care. He reported being hospitalized a couple years prior.

The patient had no acute general medical issues other than left shoulder pain; he had chronic conditions that included chronic obstructive pulmonary disease (COPD) with bronchitis and history of hepatitis C, as well as malnutrition with weight loss. He was medically screened upon admission with laboratory assessment and physical examination that were grossly normal or unremarkable. Shoulder x-ray did not reveal a fracture. He was tobacco dependent at one-fourth pack per day.

The patient is single and unemployed. There was no history of legal issues or trauma history in this case. Psychosocial stressors included primary support, economic, occupational, social environment and general medical domains.

Evaluation on admission revealed a mental status examination that reflected reasonable motivation for rehabilitation treatment, but limited insight and coping skills. The patient was described as cooperative with fluent speech and organized thought processing. He displayed euthymic mood with no severe symptoms such as mania, psychosis, perceptual disturbance or severe cognitive impairment. He did not report suicidal ideation or aggressive impulses. There were withdrawal symptoms or post-acute withdrawal symptoms with a Clinical Opiate Withdrawal Scale (COWS) score of 17 including chills, tremors, muscle aches and joint pain, piloerection, rhinorrhea, yawning, and restlessness with anxiety.

Upon admission to inpatient level services, the patient received comprehensive evaluation and treatment that included counseling, group sessions, education, and other therapeutic activities. Psychiatric evaluation had been provided and affirmed that the patient had no acute symptoms of the co-occurring psychiatric disorder(s). The patient engaged in substance use disorder rehabilitation treatment. He was adherent with medication that included vitamin supplements and the availability of nicotine replacement to address tobacco dependence, as well as as-needed (PRN) use of medications for pain and insomnia and elevations in blood pressure. He received methadone at 500 milligrams per day.

Throughout his brief inpatient stay, the patient remained stable and engaged with the treatment regimen. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged and referred to a residential program for continued rehabilitation substance use disorder treatment, as well as recommendation for follow up with his primary care physician. 

No, the requested inpatient stay for rehabilitation treatment is not medically necessary for this patient.
The patient received inpatient level rehabilitation treatment. He was receiving methadone maintenance treatment in the community. As the health plan asserts, the patient had no significant general medical or psychiatric comorbidity that would have warranted acute inpatient level care, and presented with no complicated withdrawal or safety concerns such as suicidality or aggressive impulses. He was motivated to engage in rehabilitation treatment. Thus, the patient did not meet New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, as the health plan asserts in the denial.

During the time interval under review, the patient was noted to be in no apparent distress or mild distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers. During his brief inpatient stay prior to discharge, there were no complicating treatment issues that would have warranted inpatient level of care, structure or 24-hour monitoring. The application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting, as the health plan also asserts and contrary to the appeal. Thus, the argument on appeal noted below is not consistent with New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, and medical necessity for the inpatient level care for substance use disorder rehabilitation treatment is not met in this case scenario, consistent with the American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.

Yes, the health plan has acted reasonably, with sound medical judgment and in the best interest of the patient.
The patient in this case scenario is not clinically appropriate for an inpatient level of care for the time interval under review. The patient had presented with a level of stability that included no complicated withdrawal symptoms or biomedical issues, and no co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care. He did not need the monitoring or the structure of an acute inpatient setting in order to receive effective substance use disorder rehabilitation treatment. Moreover, he was motivated for treatment and was already involved with methadone maintenance treatment and peer-supported recovery groups that could have been provided in a less restrictive treatment setting in order to address the comorbid opioid, cocaine and alcohol use disorders. Thus, the health plan's determination is reasonable in this case scenario. 

This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines/Criteria, referenced below.