Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polysubstance Abuse (Cocaine, Cannabis, Alcohol, Nicotine). 
Treatment: Substance Abuse Inpatient Rehabilitation Admission. 

The insurer denied the substance abuse inpatient rehabilitation admission. 
The health plan's determination is upheld. 

The patient is a male who was admitted to inpatient rehabilitation substance use disorder treatment of stimulant (cocaine), alcohol, and cannabis (marijuana) use disorders. The patient was using cocaine with intranasal administration together with daily use of marijuana (2 to 3 blunts) and use of alcohol with one nip and two beers. The patient was also tobacco dependent at one pack per day. His referral was prompted by his desire to stop using substances of abuse after longstanding use for half of his life. He had a history of multiple past substance use disorder treatment episodes with the more recent rehabilitation treatment with up to 14 months of sobriety. 

The patient has poorly controlled diabetes mellitus and he presented with an elevated glucose, as well as an elevated blood pressure with no history of hypertension. There were no other acute general medical issues that were a focus of treatment. The patient was medically cleared at the time of admission and his laboratory assessment was normal or unremarkable other than elevated blood glucose determinations and a positive drug screen consistent with history. There was no co-occurring psychiatric disorder or history of psychiatric hospitalization or suicidal behavior. 

The mental status examination revealed a cooperative male with clear speech and linear thought processing that was goal directed. His mood was anxious with congruent affect. The patient's thought content included no morbid thoughts. He had no evidence of cognitive impairment, perceptual disturbance, mood disturbance or psychosis. His insight was limited with impaired judgment due to the addictions. He had sleep disturbance with insomnia. 

The inpatient level substance-related rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions, and recovery groups with peer support. The patient easily transitioned to rehabilitation treatment. He actively participated in individual, group, and educational sessions. He was prescribed Gabapentin, Melatonin, Trazodone and vitamins with the availability of nicotine replacement therapy throughout his stay. 

Discharge planning occurred that included a recommendation for continued aftercare upon completion of the program. The patient was cooperative and engaged throughout his inpatient stay with reasonable motivation and participation in therapeutic activities. He indicated that he was going to remain sober. There were no psychiatric or biomedical complications during his stay with discharge. 

The structure and intensity of services necessary for the rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that the inpatient level structure and 24-hour nursing monitoring is medically necessary for a successful outcome in this case. There were no biomedical, psychiatric, or general medical issues that warranted the requested inpatient level services. The diabetes and elevated blood pressures were amenable to management with lower-level services. 

The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to receive effective treatment for a co-occurring disorder (schizophrenia).