Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient Substance Abuse Admission.
The insurer denied the Inpatient Substance Abuse Admission.
The denial is upheld.

The patient is an adult male referred for inpatient rehabilitation and substance use disorder treatment in order to address opioid (heroin) and stimulant (cocaine) class substance use disorders. The patient had been using opioid and cocaine substances of abuse while participating in an outpatient Suboxone treatment program. His referral was prompted by his failure to remain abstinent while in outpatient substance use disorder treatment, as well as the potential for jeopardizing his ability to function at work and socially. Also, his request for substance-related services was motivated by his desire to maintain a healthier lifestyle. His referral had followed treatment with detoxification at another facility.

The patient has a longstanding history of substance use disorder beginning in adolescence with multiple past treatment episodes with detoxification and rehabilitation services ultimately resulting in his participation with medication assisted treatment for the opioid use disorder with Suboxone. He was unable to remain sober and abstinent from substances of abuse with use of up to one-half gram of heroin daily with snorting and daily use of cocaine with smoking/inhalation, and had tested positive for opioids (methadone and buprenorphine) and cocaine prior to his admission for inpatient level substance use disorder treatment.

Upon entering treatment with inpatient level services, the patient received comprehensive evaluation and treatment that included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and, involvement with therapy groups, as well as recovery groups and other therapeutic activities to support his efforts at rehabilitation treatment. The patient engaged in substance use disorder rehabilitation treatment, but indicated that he was planning to cut treatment short due to the pending real estate transaction. 

Throughout his brief inpatient stay, the patient remained stable with regard to mental status and remained engaged with respect to the treatment regimen including focus on coping skills and plan for the development of a relapse prevention plan while providing motivational enhancement. He received Suboxone and vitamin supplements and melatonin with prn (as needed) use of gabapentin and trazodone, as well as comfort medications. 

The patient continued treatment with intensive services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged against medical advice with a Narcan kit and with recommendations for clinically appropriate aftercare. The patient indicated that he planned to return to his Suboxone treatment program.

No, the requested benefit of Inpatient admission is not medically necessary for this patient.

The patient presented with substance use disorders with use of opioid and stimulant class substances while participating in an outpatient substance use disorder treatment program with medication assisted treatment with Suboxone. He had relapsed with drug screen positive for opioid and cocaine substances of abuse, including buprenorphine and methadone, as noted in the clinical summary. Upon referral for substance use disorder treatment, the patient engaged in treatment, but left due to a pending real estate transaction and his desire to return to the Suboxone treatment program, and to maintain his employment and relationship with his girlfriend.

During the time interval under review, the patient was noted to be in no apparent distress with satisfactory daily functioning and active participation in treatment including positive interactions with staff and peers. There were no emerging treatment issues or biomedical or co-occurring psychiatric issues that would have warranted the inpatient level of care. The application of NY State OASAS LOCADTR Criteria (New York State Level of Care for Alcohol and Drug Treatment Referral) did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity is not met in this case scenario and this answer is consistent with ASAM (American Society of Addiction Medicine) Criteria, the scientific literature and published guidelines, referenced below.

Yes, the health plan has acted reasonably, with sound medical judgment and in the best interest of the patient.
The patient in this case scenario is not clinically appropriate for the admission or continued inpatient level of care during the time interval under review. The patient's clinical features did not include residual withdrawal symptoms, biomedical complications or co-occurring psychiatric symptoms or disorders that would have warranted inpatient level care. His treatment did not require 24-hour monitoring or the structure or intensity of inpatient level services. He reasonably engaged with treatment despite questionable motivation, and was involved with recovery groups while participating in educational sessions and other evidence-based treatment to address the substance use disorders. The patient could have been safely and effectively treated in a lower level of care in a less restrictive setting with sober supports and clinically appropriate monitoring to assure abstinence. Thus, the health plan's determination is reasonable in this case scenario. This answer is consistent with prevailing standards of medical practice for the substance use disorders diagnosed and under treatment in this case, as well as the NY State OASAS LOCADTR (New York State Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria/Guidelines, referenced below.