Appeal type: Medical necessity
Decision: Upheld

This is a patient who was admitted to residential rehabilitation substance use disorder treatment of opioid (heroin) use disorder.  The patient was using two bags of heroin on a frequent basis with intranasal administration (smoking).  His use of heroin was causing significant risk to his health and impairing his ability to function.  His self-referral was prompted by legal issues with mandated treatment for his opioid use disorder.  Thus, the patient was externally motivated to engage in substance use disorder treatment.  The patient has no acute or chronic general medical issues that were a focus of treatment, though he is treated for hypertension with lisinopril.  His laboratory assessment and physical examination was normal or unremarkable, and the patient had been medically cleared for substance use disorder residential level treatment.
There are no co-occurring psychiatric disorders in this case other than a history of insomnia treated with either doxepin or quetiapine.  The patient denied psychiatric hospitalization or suicidal behavior.
Mental status examination revealed a cooperative male with clear speech and linear thought processing that was goal directed.  Thought content included no morbid thoughts.  Insight was fair with impaired judgment due to the addiction and poor control of impulse to use due to cravings.  There were no severe symptoms such as mood disturbances, psychosis, cognitive impairment or perceptual disturbances, or suicidal ideation or aggressive impulses.  There were no somatic concerns other than insomnia.  The patient is married with a young son.  He is college educated with an associates degree and employed.  He has legal issues with mandated treatment.  Family history of mental illness and substance use disorder is negative.  The patient had no report of trauma or abuse.
The residential level substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions and recovery groups with peer support.  The patient engaged with rehabilitation treatment and actively participated in individual, group and educational sessions.  He continued to struggle with cravings, though he endorsed a commitment to a recovery process with the goal of achieving sobriety and abstinence from substances of abuse.  He used cocaine while on a pass, and he used heroin with a peer while on pass.  Nonetheless, he continued to attend groups and other therapeutic sessions including work on a relapse prevention plan and submission to random drug screening.  The treatment team indicated that the patient needed more time, in view of the lapses, on including continued work on the relapse prevention plan and development of coping skills.  Discharge planning occurred with plans for continued intensive substance use disorder treatment, and involvement in recovery groups with sober supports and use of a relapse prevention plan.
Records reviewed include case records and the health plan documents, appeal documents, correspondence from the health plan and treatment facility, as well as the health plan's rationale for denial of the requested inpatient rehabilitation services.  This is a New York State mandated review including application of New York State OASAS LOCADTR 3.0 Criteria.  The health plan's determination is upheld.
The patient was amenable to treatment at a lower level of care.  The patient was motivated and capable of effectively continuing in substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing.  The patient did not need the structure or monitoring of a residential setting in order to effectively participate in rehabilitation substance abuse treatment, or to participate in peer-supported recovery groups or receive other evidence-based treatment such as medication assisted treatment.
There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the continued residential level services and treatment, as requested.

This answer is consistent with prevailing standards of professional practice, American Society of Addiction Medicine (ASAM) Criteria, and the published guidelines and the scientific literature as well as the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, referenced below.