Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Substance Abuse Inpatient Rehabilitation
The insurer denied: Substance Abuse Inpatient Rehabilitation
The denial is Upheld

The patient is an adult male. He self-referred for inpatient rehabilitation and substance use disorder treatment beginning three months ago. 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 has no history of withdrawal seizures or delirium tremens. His substance use included $60 worth of crack cocaine and 3 to 4 bags of heroin with intranasal administration on a daily continuous basis, and daily use of marijuana with one to two joints. The patient has an extensive history of substance use disorder treatments with detoxifications and rehabilitation treatment but no sustained sobriety or abstinence despite receiving methadone maintenance assisted treatment. He had no significant withdrawal symptoms but did report mild symptoms. Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. 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 became belligerent and was discharged administratively with plans for clinically appropriate aftercare of his substance use disorders and referral back to the methadone clinic. The health plan denied coverage of the requested dates of service based on New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3 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 of care in a less restrictive treatment setting.

The treatment facility appealed based on New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3 Criteria and submitted records, indicating that inpatient level treatment was the appropriate level of care.

The Inpatient Rehabilitation Admission was 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. The application of NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 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, also as the health plan asserts. Thus, medical necessity for the Inpatient substance use rehabilitation treatment for the dates of (American Society of Addiction Medicine) Criteria, the scientific literature, and published guidelines, referenced below, and with the application of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria.

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review. The patient had presented with a level of medical stability and had no co-occurring psychiatric disorders or safety issues that would have warranted inpatient level care.