Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Alcohol Use Disorder.
Treatment:  Inpatient Rehabilitation Admission.

The insurer denied Inpatient Rehabilitation Admission.  The denial is upheld.

The patient is an adult male who received detoxification treatment and was immediately referred and admitted for inpatient rehabilitation substance use disorder treatment beginning 5 months ago in order to address use severe alcohol use disorder. The patient has a history of withdrawal seizures and frequent blackouts, but no history of delirium tremens. He had an extensive history of detoxification treatments and rehabilitation treatment with relapses; the more recent substance related treatment was 7 months ago when he had left treatment against medical advice (AMA). During his longstanding use of alcohol, he reported only four months of abstinence. Upon admission to inpatient level services, the patient received 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 peer-supported recovery meetings. He agreed to medication-assisted treatment with naltrexone/Vivitrol. He received intensive rehabilitation services, monitoring, and structure including 24-hour nursing monitoring and was discharged after completion of 21 days of inpatient rehabilitation treatment with referral for clinically appropriate care as an outpatient with MAT (medication-assisted treatment) and plan to work on developing sober supports, as well as arrangements for general medical care.

During the time interval under review, the patient had no significant withdrawal or post-acute withdrawal symptoms, no safety concerns, and no psychiatric or biomedical complications. The denial is being appealed based on the clinical features and treatment dimensions in the case including the longstanding history of alcohol use and treatment history with a chronic relapsing clinical course, as well as the lack of sober supports, legal history and inability to hold a job, as well as the history of frequent blackouts and withdrawal seizures and general medical comorbidity.

The Inpatient Rehabilitation Admission is not medically necessary for this patient, in keeping with prevailing standards of care including societal guidelines and the scientific literature pertaining to rehabilitation treatment of alcohol use disorder and with regard to 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 instruction for this binding medical necessity review.

The health plan's determination is clinically appropriate in keeping with prevailing standards of medical practice. In this case, the patient could have been reasonably managed with lower-level care in a less restrictive treatment setting, as the health plan asserted in the denial determination.

The patient presented with substance use disorder, diagnosed with severe alcohol use disorder. He was medically screened and had received detoxification treatment. He received inpatient level rehabilitation treatment and readily engaged in treatment and had no significant biomedical (withdrawal symptoms or signs) or psychiatric treatment issues and continued treatment for the hypertension, as well as receiving medication assisted treatment and continued vitamin replacement therapy. 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, as well as LOCUS (Level of Care Utilization System) and ASAM (American Society of Addiction Medicine) 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 asserts.