Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male who presented for inpatient level substance use disorder rehabilitation treatment to address substance use of stimulants (crack cocaine); cannabis (marijuana); and alcohol class substances. He had a history of substance use disorder with alcohol and marijuana, escalating to daily continuous use with subsequent use of cocaine. His substance use had resulted in psychosocial problems including legal issues in the past.

The patient was motivated for rehabilitation treatment. The patient exhibited limited insight and impaired judgment with questionable control of impulses. There were no severe symptoms on mental status examination; the patient had no symptoms of severe depression, mania, psychosis, perception, cognition, or thought disorder. He denied problems with energy, concentration, sleep or appetite.
The patient had no acute general medical conditions except for a stye in his eye that had been present for several weeks. There were no chronic medical conditions in this case.

The rehabilitation treatment included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with 12-step recovery groups. The patient engaged in treatment and intensive services, monitoring and structure provided within the inpatient treatment program. The patient participated actively with treatment and showed no significant symptoms or signs of withdrawal or post-acute withdrawal symptoms which had been present during his detoxification. He readily engaged in rehabilitation treatment and he had no complications other than ongoing concern with the status of the stye in his left eye which had not improved. As his concern for the stye increased he indicated that would seek medical treatment elsewhere and left the program with discharge against medical advice (AMA). The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

No, the requested health service/treatment of Inpatient Stay is not medically necessary for this patient.  The patient was motivated and able to effectively engage in rehabilitation services, and the patient did not need the continued structure or monitoring of an inpatient setting or the intensity of therapy and services in order to effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms in this case that would have required inpatient level substance-related services. Moreover, the patient was motivated to participate in rehabilitation treatment and was fully engaged in the treatment, and only left treatment to seek help with his comorbid medical condition, a stye in his eye. Thus, the requested inpatient stay for substance use disorder was not medically necessary for this patient and could have been effectively provided at a lower level of care.
This answer is consistent with prevailing standards of professional practice, the published practice guideline, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well 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 Guidelines/Criteria, referenced below.