Appeal type: Medical necessity
Decision: Upheld

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

The case involves a male who self-referred with admission to inpatient rehabilitation and substance use disorder treatment beginning to primarily address substance use disorder with alcohol and crack cocaine. The patient has no history of withdrawal seizures or delirium tremens. He was also diagnosed with opioid use disorder and in medication assisted treatment with methadone 100 milligrams daily. He had been using up to 40 ounces of beer and $50 worth of crack cocaine daily, as well as taking his methadone prescribed with a methadone maintenance treatment program (MMTP). He had past treatment experience with at least seven detoxification treatment episodes and the ongoing methadone maintenance treatment program. His drug screen was positive for cocaine, benzodiazepines and methadone.

Upon admission to 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 groups, as well as peer-supported recovery groups and other therapeutic activities. Psychiatric evaluation had been provided and affirmed that the patient had no co-occurring psychiatric disorders. The patient engaged in substance use disorder rehabilitation treatment. He was adherent with medication that included vitamin supplements and the availability of nicotine replacement to address tobacco dependence, as well as 'as needed' (PRN) use of medications for pain and insomnia and elevations in blood pressure. Amlodipine and metformin were continued, as well as methadone at 100 milligrams per day.

Throughout her brief inpatient stay, the patient remained stable and engaged with the treatment regimen. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged and transferred to a sister program for continued rehabilitation substance use disorder treatment.

The Issue under Review is the Inpatient Rehabilitation Services.  The denial was on the basis of New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria indicating that outpatient level care was appropriate. Additionally, the denial indicated that the patient had no significant general medical issues requiring inpatient level care, or psychiatric comorbidity and had reasonable motivation for an effort at substance use disorder treatment with Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria indicating that outpatient level referral and treatment was clinically appropriate.  The appeal was on the basis of multiple past treatment episodes with no "clean" time and a lack of coping skills, indicating that New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria were met for inpatient level rehabilitation treatment. The appeal also indicated that the lack of psychotic features was not a valid reason to deny the requested level of care.

No, the requested inpatient stay for rehabilitation treatment was not medically necessary for this patient.
The patient received inpatient level rehabilitation treatment. He self-referred for treatment with family support and had not received multiple past substance use disorder treatments including at least seven detoxification treatments with relapses. He was receiving methadone maintenance treatment. As the health plan asserts, the patient had no significant general medical or psychiatric comorbidity and presented with no complicated withdrawal or safety concerns such as suicidality or aggressive impulses. He was motivated to engaged in rehabilitation treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. Thus, the patient did not meet Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria as the health plan asserts in the denial.

During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers. During his brief inpatient stay prior to transfer, there were no complicating treatment issues that would have warranted inpatient level of care, structure or 24-hour monitoring. The application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting, as the health plan also asserts. Thus, the argument on appeal noted below is not consistent with Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria and medical necessity for the inpatient level care for substance use disorder rehabilitation treatment and is not met in this case scenario, consistent with the American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.

Note: The appeal was on the basis of multiple past treatment episodes with no "clean" time and a lack of coping skills, indicating that New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria were met for inpatient level rehabilitation treatment. The appeal also indicated that the lack of psychotic features was not a valid reason to deny the requested level of care.

The patient in this case scenario is not clinically appropriate for an inpatient level of care for the time interval under review. The patient had presented with a level of stability that included no significant withdrawal symptoms or biomedical issues and no co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care. He did not need the monitoring or the structure of an inpatient setting in order to receive effective substance use disorder rehabilitation treatment. Moreover, he was motivated for treatment and was already involved with methadone maintenance treatment and peer-supported recovery groups that could have been provided in a less restrictive treatment setting in order to address the comorbid cocaine and alcohol use disorders. Thus, the health plan's determination is reasonable in this case scenario-noted below. This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines/Criteria, referenced below.