Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction/Polysubstance Use/Alcohol and Substance Abuse/Addiction.
Treatment: Inpatient Rehabilitation Treatment, 25 Days.
The health plan denied Inpatient Rehabilitation Treatment, 25 Days as not medically necessary. 
The health plan's determination is upheld.

The case involves an adult male who was self-referred with admission to inpatient rehabilitation and substance use disorder treatment to address substance use disorders with alcohol and cocaine. The patient had no history of blackouts or withdrawal seizures or delirium tremens. He had been using up to 1 pints of liquor daily with daily use of cocaine with intranasal administration. He had multiple past treatments with the most recent detoxification immediately prior to his admission. He presented with no significant withdrawal symptoms. He reported craving and urges to use and had drug dreams during his first week of treatment. The patient was a non-smoker.
The patient has a history of a psychiatric disorder best characterized as unspecified depressive disorder associated with anxiety and was treated with Escitalopram and Gabapentin. He has a remote history of a psychiatric hospitalization. There is no history of suicidality.
The patient had no acute general medical issues; he had a diagnosis of hypertension, diabetes mellitus, gastroesophageal reflux disease (GERD) and arthritis of the knee treated with Amlodipine, Lisinopril, Metformin and analgesics. His laboratory assessment was normal or unremarkable and his drug screen was positive and consistent with his history.
The patient is single and unemployed with no family support. He was housed and reported that peers and his roommate were using substances of abuse. There were no legal issues. He reported no trauma history.
Evaluation on admission revealed a mental status examination that reflected reasonable motivation for rehabilitation treatment, but limited insight and coping skills. The patient was described as cooperative with fluent speech and organized thought processing. He displayed euthymic mood with no severe symptoms such as mania, formal thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. He did not report suicidal ideation or aggressive impulses. There were no significant or severe withdrawal symptoms or post-acute withdrawal symptoms, though he had cravings and urges to use. He reported insomnia.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service/treatment of Substance Use - Inpatient Rehabilitation Treatment, 25 Days was not medically necessary for this patient.

The proposed inpatient substance disorder treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided with an alternate level of care in a less restrictive treatment setting. The clinical features and indicated treatment dimensions of this patient's alcohol and cocaine use disorders did not require or warrant the structure or monitoring or intensity of treatment of an inpatient level service. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cocaine. Moreover, the patient had been evaluated and cleared with regard to safety concerns, and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment.