Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction
Treatment: Substance abuse inpatient rehabilitation admission
The health plan denied: Substance abuse inpatient rehabilitation admission
The determination is: Upheld

The patient is a male who was admitted to inpatient rehabilitation for substance use disorder as treatment of stimulant (cocaine), alcohol, and cannabis (marijuana) use disorders. The patient was using up to $100 worth of crack cocaine together with $50 worth of marijuana with daily use, and use of alcohol with one and one-half pints of rum and two beers daily. The patient was also tobacco dependent. His referral was prompted by his desire to stop using substances of abuse after longstanding use since adolescence. He had a history of multiple past substance use disorder treatment episodes with at least ten or more detoxification treatment episodes with the last occurring for five days.
There was a history of co-occurring psychiatric disorder best characterized as schizophrenia with depression or bipolar disorder with a history of psychiatric hospitalization due to suicidal risk. The patient is single, homeless and housed, and unemployed with an 8th grade education and public assistance. Peers were using substances of abuse, and he had limited social support. He denied legal issues.
Mental status examination revealed a cooperative male with clear speech and linear thought processing that was goal directed. His mood was anxious with congruent affect. The patient's thought content included no morbid thoughts. He had no evidence for cognitive impairment, perceptual disturbance, mood disturbance, or psychosis. His insight was limited with impaired judgment due to the addictions. He had sleep disturbance with insomnia.

The inpatient level substance-related rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions, and 12-step recovery groups with peer support. The patient easily transitioned to rehabilitation treatment. He actively participated in individual, group, and educational sessions. He was prescribed comfort medications and vitamins with the availability of nicotine replacement therapy and as needed (prn) medications to address anxiety and insomnia.

Discharge planning occurred that included recommendation for continued aftercare upon completion of the program. However, the patient left treatment against medical advice indicating that he was uncomfortable because his sister had been admitted to the treatment facility.

At issue is the medical necessity of substance abuse inpatient rehabilitation admission.
The health plan's determination of medical necessity is upheld. The requested health service/treatment of Substance Abuse Inpatient Rehabilitation Level of Care was not medically necessary for this patient.

The Inpatient substance use disorder rehabilitation services in this case scenario were amenable to treatment at an alternate level of care. The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with sober support and/or housing. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to receive effective treatment for the co-occurring disorder (schizophrenia or bipolar disorder with depression).

There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and the continued inpatient level services and treatment. Thus, the requested benefit of inpatient substance use disorder rehabilitation services was not medically necessary in keeping with NY (New York) State Guidelines.