Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient rehabilitation services.
The insurer denied the Inpatient rehabilitation services.
The determination is upheld.

The patient presented for inpatient rehabilitation substance use disorder treatment to address substance use disorder with alcohol. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. She had a long history of alcohol use with progression of the disease and a chronic relapsing course. Her referral to inpatient level followed a detoxification treatment episode with immediate transfer to rehabilitation services for treatment. The patient has an extensive history of substance-related treatments including eight detoxification treatments and at least two prior rehabilitation treatments with outpatient aftercare. Her relapses were triggered by ongoing psychosocial stressors and relationship problems in the context of co-occurring mood and anxiety disorders.
The patient has a history of psychiatric disorders best characterized as bipolar mood disorder with episodes of major depression and an unspecified anxiety disorder treated with Paxil and Geodon. There was no recent history of psychiatric hospitalization, or suicidal, or self-harming behaviors.
There were no acute general medical issues in this case. The patient had been medically screened at the time of admission. She had chronic conditions that included hypertension, dyslipidemia, bronchial asthma, and gastroesophageal reflux disease (GERD) with a history of hepatitis. Laboratory assessments and electrocardiogram (EKG) were normal or unremarkable. The patient was tobacco dependent and indicated that she also used marijuana; she did not use other substances of abuse.
Evaluation on admission for residential level services revealed a mental status examination that was free of severe psychiatric symptoms. She was generally motivated for rehabilitation treatment and had limited psychosocial support. The patient was described as cooperative with fluent speech and linear thought processing with a hopeful outlook. She had no evidence of acute mania, thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. She did not report suicidal or homicidal ideation. There were somatic complaints related to post-acute withdrawal symptoms including tremor and watery eyes, and insomnia.
The patient is single, unemployed and lives in supported housing. She had limited coping skills. There were no legal issues or trauma history in this case.
The patient was admitted to inpatient rehabilitation with comprehensive rehabilitation treatment that included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and, involvement with groups and individual therapy, as well as 12-step recovery groups and other therapeutic activities to enhance motivation to engage in a recovery effort. Psychiatric evaluation was provided, and the consultant confirmed the co-occurring psychiatric disorders with continued use of Geodon and Paxil. General medical conditions were treated with Norvasc, Zocor and comfort medications, as well as continued vitamin replacement therapy.
Throughout the inpatient stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the inpatient treatment program. During her inpatient stay, the patient was participating actively in treatment with continued risk for relapse; the patient had no severe post-acute withdrawal symptoms; and, she had no complications with respect to biomedical, general medical, emotional or other treatment domains. Mental status examinations/progress notes reflected sleep, appetite and energy that were okay and improving functioning. The patient continued to make satisfactory progress and was discharged with clinically appropriate aftercare and recommendations to continue involvement in recovery groups and return home while participating in outpatient treatments. Additionally, she was referred for mental health and primary care with an appointment within two weeks and continuation of her medications as indicated.
At issue is the medical necessity of Inpatient Substance Use Disorder Rehabilitation Services.
The requested health service/treatment of inpatient rehabilitation services is not medically necessary for this patient.
The patient presented with severe alcohol use disorder with transfer from detoxification treatment to inpatient level substance use disorder rehabilitation treatment. She received inpatient level rehabilitation treatment with inpatient structure and 24-hour monitoring. She readily engaged in treatment with evidence-based psychosocial treatments. During the time interval under review, the patient was noted to be in no apparent distress with satisfactory functioning and active participation in treatment including positive interactions with staff and peers. Throughout her stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care. The application of NY State OASAS LOCADTR Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting. Thus, medical necessity for the admission and continued Inpatient stay through discharge is not met in this case scenario, consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature, and published guidelines, referenced below.
This answer is consistent with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below, and is entirely consistent with NY State instruction for this review including the appropriate application of the NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.