Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance Abuse.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male, who received detoxification treatment and presented for inpatient level substance use disorder rehabilitation treatment to address use of stimulants (cocaine), cannabis (marijuana), and alcohol class substances.  The patient was tobacco dependent at one-half pack per day; he had no past history of delirium tremens or withdrawal seizures.  He reported onset of alcohol and marijuana use at a very early age, escalating to daily continuous use together with crack cocaine with up to $100 per day, and alcohol with up to sixteen 24-ounce beers, and daily use of up to $30 worth of marijuana that had resulted in past legal issues and other current psycho-social problems. 

The patient had previously engaged in substance use disorder treatment with relapses.  He had a history of being incarcerated.  He was unemployed and disabled with chronic conditions that included back pain, asthma, gastroesophageal reflux disease (GERD), arthritis and glaucoma with associated treatments.

There was a history of psychiatric disorder and treatment for depression, and the patient has a history of psychiatric hospitalization, but he denied suicidal or self-harming behaviors.

The patient was motivated for rehabilitation treatment.  The patient exhibited fair, but limited insight and fair judgment and control of impulses except when using substances. 

There were no severe symptoms on mental status examination; the patient had no symptoms of mania, psychosis, perception, cognition, or thought disorder.  The patient was described as "groomed" and "cooperative" with good eye contact.  He was depressed and exhibited anxiety and complained of insomnia.  He did not present with post-acute withdrawal symptoms. 

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, sober housing, monitoring, and structure provided within the inpatient treatment program.  The patient participated actively with treatment, and showed no significant symptoms or signs of withdrawal, and had no complications of rehabilitation treatment.  The patient participated in activity therapies and other therapeutic interventions to improve insight and life skills.  He received vitamins, and psychotropic medications, Lexapro and trazodone.  Again, the patient was engaged in rehabilitation treatment, and a discharge plan was in place including involvement with 12-step recovery groups and work on a relapse prevention plan.  However, he requested discharge against medical advice due to a dispute over his property. 

No, the proposed treatment of Inpatient Admission was not medically necessary for this patient.

The substance abuse rehabilitation services in this case scenario were amenable to treatment at a lower level of care.  The patient was motivated and able to effectively engage in rehabilitation services, and the patient did not need the structure or monitoring of an inpatient setting or 24-hour monitoring in order to safely and effectively participate in rehabilitation substance use disorder rehabilitation treatment.  There were no biomedical or psychiatric complications, or severe psychiatric symptoms in this case that would have required continued inpatient level services and rehabilitation treatment.  Moreover, the patient had support for the substance use disorder treatment with access to sober housing and peer support, and he was motivated to participate in rehabilitation treatment, as noted.  Thus, the requested benefit of Inpatient Admission was not medically necessary.

This answer is consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as New York State instruction regarding medical necessity reviews and the application of NY (New York) State OASAS Office of Addiction Services and Supports Level of Care Determination (OASAS LOCADTR) 3.0 Criteria, referenced below.

The patient had received detoxification treatment and he was motivated to actively engage in rehabilitation treatment without biomedical complications or significant withdrawal or post-acute withdrawal symptoms.  He had prior exposure to substance use disorder treatment and 12-step recovery principles and was able to engage and participate actively in the treatment plan without complication.  There were no severe psychiatric disturbances or general medical concerns that required inpatient level services, structure or monitoring.  The patient was noted to benefit in all aspects of his treatment plan throughout his stay despite his decision to leave treatment against medical advice.  He had access to sober housing from which substance use disorder treatment could be received.  Thus, the patient's substance use disorder rehabilitation treatment could have been effectively provided at a lower level of care including sober housing, and other supportive services in the community including peer support through 12-step recovery groups such as Alcoholics Anonymous (AA).  Moreover, the application of NY State Office of Addiction Services and Supports Level of Care Determination (OASAS LOCADTR) 3.0 Criteria/Guidelines does not support treatment at the inpatient level of care, as the health plan asserts.