Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorder
Treatment: Inpatient Rehabilitation Admission
The insurer denied: Inpatient Rehabilitation Admission
The denial is upheld

The patient is an adult male who self-referred for inpatient rehabilitation and substance use disorder treatment. The patient has longstanding substance use disorders with cannabis and stimulant (crack cocaine) and opioid (heroin) class substances with prior treatment with a chronic relapsing course. The patient had an extensive history of substance use disorder treatments with detoxifications and rehabilitation treatment but no sustained sobriety or abstinence. He was receiving medication assisted treatment with methadone at 70 milligrams daily.
He had no significant withdrawal symptoms but did report mild symptoms. The patient was described as cooperative. Upon admission to inpatient level services, the patient received a comprehensive evaluation and treatment that included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with groups, as well as participation in peer-supported recovery groups and other therapeutic activities. The patient engaged in substance use disorder rehabilitation treatment. He was noted to be engaged in therapeutic activities, social with peers, and participating in recovery groups. He was prescribed his usual dose of methadone. Throughout his inpatient rehabilitation stay, the patient remained stable with mental status and remained 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 after completion of his inpatient treatment with plans for clinically appropriate aftercare. The issue under review is inpatient substance-related rehabilitation treatment.
The denial was based on New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria indicating that there were no acute psychiatric or general medical problems that would have required inpatient level services and indicating that the patient's admission was not medically necessary, as treatment could have been provided with lower-level care in a less restrictive treatment setting.  
The treatment facility appealed based on New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria indicating that inpatient level treatment was the appropriate level of care referencing barriers to residential treatment and the clinical features and treatment dimensions in this case.

The requested inpatient substance use rehabilitation treatment is not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with cannabis and stimulant/cocaine and opioid and tobacco use disorders. He self-referred and received inpatient level rehabilitation treatment with continued use of methadone. He readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. During the time interval under review, the patient was noted to be in no apparent distress other than insomnia that responded to treatment, and he displayed reasonable functioning and active participation in treatment. Thus, medical necessity for the inpatient substance use rehabilitation treatment for the dates of service under review is not met in this case, consistent with the American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, and 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 Criteria.