Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cannabis use disorder
Treatment: Substance Abuse: Inpatient stay

Summary:
The patient is an adult male. He was admitted to inpatient level services for treatment of cannabis use disorder; the patient had been using cannabis (marijuana/hashish) with up to one-half gram one to three times per month. His self-referral was prompted by his parole officer in lieu of returning to prison. He had a past history of formal substance use disorder treatment with one treatment episode resulting in 28 months of sobriety. He had relapsed in response to grief related to the death of his brother who had succumbed to an overdose. The referral to inpatient level substance use disorder treatment was therefore related to ongoing problems with maintaining abstinence from cannabis use in the context of probationary legal status. 

The patient has no acute or significant chronic general medical issues. He had a remote history of a withdrawal seizure related to benzodiazepine use, and he was hepatitis C positive without treatment and with a past history of IV drug use with heroin. Medical screening was negative and unremarkable. The patient denied use of other substances of abuse other than tobacco with use of one-half pack per day. There is a history of psychiatric disorder and treatment for posttraumatic stress disorder (PTSD) and unspecified anxiety and depressive disorders with citalopram and hydroxyzine. He denied past history of psychiatric hospitalization or suicidal behavior/suicide attempt.

The patient's Mental Status Examination revealed no severe symptoms, and the patient was cooperative and euthymic with normal speech, thought processing and no evidence for mania, psychosis, cognitive impairment or perceptual disturbance. He denied suicidal ideation or aggressive impulses. He lacked coping skills and demonstrated only fair insight. He had symptoms of anxiety and grief symptoms related to the recent loss of his brother.

The inpatient level substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, education and 12-step recovery groups with peer support. Comfort medications were available as needed, and he was prescribed vitamins and had the availability of nicotine replacement therapy, as well as continued use of hydroxyzine for anxiety. 

The patient engaged in substance use disorder treatment with active involvement in group and educational sessions, as well as other therapeutic interventions to support healthy living and the development of sober supports. The patient was noted to adjust easily to the treatment program. In this regard, the patient worked on coping skills and a relapse prevention plan with the identification of triggers including peer support to address the negative influence of the social environment. The patient remained engaged throughout the inpatient stay with satisfactory progress and transferred to outpatient level treatment  with the approval of his parole officer. He returned home. He was encouraged to continue involvement with 12-step recovery groups, as he had before with the obtainment of a sponsor.

The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was externally motivated and able to effectively engage in rehabilitation services, and, the patient did not need the structure or 24-hour monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment. Moreover, the patient had legal pressure for the substance use disorder treatment with fair insight, as noted in the clinical summary. Thus, the requested benefit of Inpatient rehabilitation was not medically necessary for this patient. This answer is consistent with prevailing standards of professional practice, ASAM Criteria, and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews together with the application of NY State OASAS LOCADTR 3.0 Criteria applicable in this case.