Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse 
Treatment: Inpatient rehabilitation 
The proposed treatment, inpatient rehabilitation substance use disorder treatment, was medically necessary for this patient and is consistent with NY State OASAS LOCADTR 3.0 Criteria. 

The requested benefit of inpatient substance use disorder rehabilitation treatment is considered clinically appropriate and medically necessary in order to address the immediate needs for rehabilitation of the severe substance use disorders diagnosed in this case, and to work toward relapse prevention in a patient with high risk for relapse. The admission and continued inpatient rehabilitation treatment was warranted in order to address the patient's lack of awareness of the seriousness of his illnesses with psycho-education and evidence-based psychosocial interventions; and in order to address issues within the social environment; and, in order to work on coping skills that will be necessary in building a sober support system and necessary for continued recovery efforts with community providers and re-engagement with peer-supported recovery groups that had been effective in the past. The counseling, educational sessions, and, the development of a relapse prevention plan were critical in this case together with the motivational techniques that served to facilitate gains with insight and acquisition of better coping skills and all important components of the treatment that were provided with clinically appropriate structure, intensity of services, and monitoring. It was clinically appropriate and medically necessary that the patient have 24-hour monitoring and inpatient level services prior to step down to lower level treatment, and that he be provided continued inpatient level services for the duration of the proposed treatment in order to prepare the patient for a safe and clinically appropriate disposition and discharge to the community. None of this therapeutic work could have been effectively provided at a lower level of care in view of the multiple, complicating factors in this case for the time interval under review. 

This answer is consistent with prevailing standards of medical practice and ASAM criteria, and with the scientific literature, referenced below, as well as the NY OASAS LOCADTR 3.0 Criteria. 

The patient's lack of awareness or limitations of insight together with the seriousness of his substance use disorders is illustrated by his continued use despite functional decline and severe psychosocial stressors including housing and employment issues, and in the context of depression and affective instability including hostility, anger, tension and excitability. Despite participating in a methadone maintenance program, and outpatient psychiatric treatment, the patient had continued to use multiple substances of abuse putting himself at risk for complications or death. Again, the patient had co-occurring mental health issues that were clearly triggering the patient's use of substances associated with a history of poor impulse control, insight and impaired judgment. These factors and treatment dimensions are the reason that the patient could not have been/could not be safely or effectively treated at a lower level of care during the time interval under review.