Appeal type: Medical necessity
Decision: Upheld

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

The patient is male with diagnoses of cannabis dependence, uncomplicated, and nicotine dependence, cigarettes, uncomplicated.  The question is whether inpatient rehabilitation treatment was medically necessary.

During his inpatient rehab admission, patient's treatment included a medication regimen of comfort medications. A psychiatric evaluation note notes that patient endorsed symptoms of anxiety and insomnia and was prescribed Vistaril and trazodone to help with these symptoms. He denied any hallucinations or other psychotic symptoms in spite of reportedly having been observed smiling to himself on the unit. In a progress note, he also admitted to a history of depression but denied current symptoms. Group notes indicate that the patient participated in groups focusing on developing coping skills, managing stress, and preventing relapse.  He continued to deny any safety concerns, SI/HI (suicidal ideation/homicidal ideation), or withdrawal symptoms throughout admission. Progress notes indicate that the patient did admit to marijuana cravings but was able to identify relapse triggers. Nursing notes indicate that the patient was alert and oriented throughout admission.

At issue is inpatient rehabilitation level of care.  The health plan used Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) for Substance Abuse Inpatient Rehabilitation criteria for the determination and concluded that medical necessity for an inpatient rehab level of care was not met due to the patient's lack of medical instability, being able to participate in or comply with treatment outside of a 24-hour strutted treatment setting, did not have social, emotional, or developmental barriers to participating in treatment outside of an inpatient level of care, did not have a co-occurring medical or psychiatric condition that required inpatient care, was not at risk from complications from withdrawal, was not suicidal, homicidal, or psychotic at the time of admission and initial evaluation, had access to social support, and was not experiencing symptoms or functional impairment that created an imminent risk of harm to self or others.

This decision was appealed by the facility with the managed care coordinator noting that medical staff evaluated the patient and deemed him appropriate for inpatient level of care at admission based on OASAS (New York Office of Addiction Services and Supports) guidelines. It also notes that the patient required evaluation by the facility's psych NP (nurse practitioner) after being observed pacing and laughing to himself and admitted to a history of self-injurious behavior. It notes that the patient was prescribed Vistaril and trazodone. It states that the patient lacked coping skills to remain sober and needed help to identify triggers and stress, and that he had never had any sober time (although this is contradicted elsewhere in the record).  It also states that the OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) tool does not state that a patient with a lack of psychotic symptoms should not be admitted to substance abuse treatment and that residential level of care would have required a referral.

No, the Inpatient Rehabilitation Admission was not medically necessary.
The patient's American Society of Addiction Medicine (ASAM) Patient Placement Criteria Rating was as follows:
(Dimension 1) Risk: 0-Individual fully functioning with good ability to tolerate, cope with withdrawal discomfort -No signs or symptoms of withdrawal present-No signs or symptoms of intoxication.
(Dimension 2) Risk: 0-Fully functioning with good ability to cope with or tolerate physical discomfort-No biomedical signs or symptoms are present.
(Dimension 3) Risk: 1-Subclinical mental disorder.
(Dimension 4) Risk: 0-Willingly engaged in treatment as a proactive participant, is aware of/admits to having an addiction problem and is committed to addiction treatment and changing substance abuse and adherence with psychiatric medications-Willing to cut negative influences.
(Dimension 5) Risk: 1-Some craving with ability to resist -Needs support and counseling to maintain abstinence, deal with craving, peer pressure, and lifestyle and attitude changes-Minimal risk of relapse.
(Dimension 6) Risk: 0-Has supportive environment Based on patient's risk ratings,  a lower level of care would have been appropriate for treating the patient's substance.

Additionally, the patient does not meet criteria for inpatient level of care using LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) criteria. The patient was not experiencing a life-threatening medical condition or severe psychiatric crisis, was not experiencing significant functional impairment due to his substance abuse, and was not experiencing acute withdrawal symptoms from marijuana. He did not have a history of life-threatening withdrawal syndromes. He was not experiencing a severe medical problem or serious psychiatric symptoms that needed to be managed in an inpatient rehab setting in order for treatment for his substance abuse to be effective. He did not endorse using substances in hazardous situations or in amounts or frequencies likely to imminently cause severe physical or emotional harm to self or others. He did not have any personal or interpersonal skills deficits. He was not documented to have been exhibiting predatory behavior that would have likely caused harm to others in a congregate setting. He did not report strong cravings or urges to use that were unmanageable or behavioral or emotional instability that would require stabilization with medical oversight in a residential setting. Based on LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) guidelines, the patient could have been appropriately managed at the residential rehabilitation level of care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
As noted above, the severity of patient's symptoms based on ASAM (American Society of Addiction Medicine) patient placement criteria and LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) patient placement guidelines show that the patient's condition could have been managed at a lower level of care than inpatient rehabilitation. There is no documentation of moderate or severe acute withdrawal symptoms, he did not have an acute medical condition that required inpatient treatment, and he did not endorse SI (suicidal ideation), HI (homicidal ideation), or any other severe psychiatric symptom that would require inpatient treatment. He also denied any history of any serious psychiatric diagnoses. His symptoms could have been managed at a lower level of care.