Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult female. She was referred for inpatient rehabilitation substance use disorder treatment in order to address use of alcohol, cannabis, and stimulant (cocaine) class substances. The patient has no reported history of withdrawal seizures or delirium tremens, though there was a history of severe withdrawal symptoms in the past during detoxification treatment and frequent blackouts. Her history of substance use included use of up to five 24-ounce beers per day, $50 worth of crack cocaine up to three times per month, and one to two hits of marijuana twice per week. The patient was self-referred and indicated that he was tired of feeling unwell. She had just had detoxification treatment earlier in the month with three days of rehabilitation treatment with discharge a couple weeks prior to this admission and relapse.

The patient has a history of psychiatric disorder and treatment for bipolar I disorder. She presented with severe symptoms of depression and anxiety. The patient has a history of psychiatric hospitalizations with the last four years prior to admission, and multiple detoxification and substance use disorder treatment episodes, with as many as 50 detoxifications with relapses and no evidence for outpatient follow up.

There were no acute general medical issues other than a productive cough. The patient was medically screened prior to admission. Vital signs were normal and laboratory assessment and Chest X-Ray were normal or unremarkable. The patient is tobacco dependent.

The patient is divorced and unemployed and domiciled. There were no reported legal issues, or trauma history in this case. The patient reported limited or no psychosocial support.

The patient's evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. The patient was described as cooperative with fluent speech and organized thought processing. Mood was depressed with anxious and labile affect. She had no severe symptoms such as mania, formal thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. She did not report suicidal ideation or aggressive impulses. Somatic concerns included low appetite and sleep disturbance.

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 meetings, and other therapeutic activities within the treatment milieu. Psychiatric evaluation was provided and she was prescribed Abilify and gabapentin with PRN (as needed) use of Benadryl for insomnia/sleep. Other medications included lisinopril and metformin.

The patient readily engaged in substance use disorder rehabilitation treatment. The patient was noted to be engaged in the therapeutic activities, social with peers and participating in recovery groups, and adherent with medication that included vitamin supplements and comfort medications and scheduled medications as noted. She continued to receive intensive rehabilitation services, monitoring, and structure including 24-hour monitoring. She was discharged with disposition to a halfway house and referral for clinically appropriate care of his substance use disorders with IOP (Intensive Outpatient Program) level care, and psychiatric follow up for the co-occurring mood disorder, as well as arrangements for general medical care.

During the time interval under review, the patient remained depressed, but had no significant withdrawal or post-acute withdrawal symptoms, no safety concerns, and no biomedical complications. Again, she had remained abstinent from substances, and she was motivated for treatment and committed to continue with a recovery process and rehabilitation treatment.

No, the Inpatient rehabilitation was not medically necessary for this patient.
The patient presented with substance use disorders, diagnosed with alcohol, cannabis, and stimulant/cocaine use disorders. She was medically screened and had no acute general medical issues other than a productive cough associated with tobacco use. She received inpatient level rehabilitation treatment and readily engaged in treatment and had no significant biomedical (withdrawal symptoms or signs) or psychiatric treatment issues and resumed treatment for the co-occurring psychiatric disorder-bipolar disorder, depressed phase.

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. Throughout her stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues or safety concerns that would have warranted inpatient level of care, structure or 24-hour monitoring for the time interval under review.

The application of NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria, as well as LOCUS (Level of Care Utilization System) and ASAM (American Society of Addiction Medicine) 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 asserts. Thus, medical necessity for the Admission and Continued Rehabilitation Substance Use Disorder Services is not met in this case scenario, also consistent with the scientific literature and published guidelines, referenced below, as well as prevailing standards of medical practice.

The health plan's determination is appropriate, in keeping with NY (New York) State LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria and prevailing standards of medical practice. In this case, the patient could have been reasonably managed with lower level care in a less restrictive treatment setting.