Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder
Treatment: Inpatient substance abuse services
The insurer denied inpatient substance abuse services.
The determination is overturned.


The patient received inpatient substance use disorder level of care related to his opioid use disorder. On earlier dates of service, he had been receiving inpatient detoxification level of care with a Valium taper of 5 milligrams (mg), two by mouth (PO) twice a day (BID) and buprenorphine of 4 mg PO BID. The patient also reported using three joints of marijuana daily and "two sticks" of Xanax on a daily basis. He reportedly completed detoxification and was scheduled to go to inpatient rehabilitation.

The clinical history indicated that he was positive on a urine drug screen for cannabis and opiates, though notably not benzodiazepines or other substances. He reported a diagnosis of human immunodeficiency virus (HIV) and being stable on medications. He took antihypertensive medications many years ago, but was taken off of the medications. He was reported to have high blood pressure at times during this admission. He denied any diagnosis of psychiatric issues formally in the past, though he reported some history of depression.

A clinical note indicates that he was a "consistent behavioral problem" on the unit. He had cursed out staff multiple times and was resistant to following facility policy. The patient did report an interest in medication-assisted treatment. He was judged to be at low risk for harm to self or others. The clinical notes are primarily nursing notes in a tabular format. There are relatively few narrative clinical descriptions from a physician or other provider. Additionally, some pages did not copy well such that the dates are difficult to discern. The patient had a modestly elevated blood pressure at various times during his admission, consistent with the prior history of hypertension. The patient was participating in therapeutic offerings, though at times he was irritable and agitated towards staff members.

At issue is the medical necessity of inpatient substance abuse services.

The inpatient substance abuse services were medically necessary.

Responses to the questions on the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool for concurrent review are as follows. The patient had no change in status requiring a higher level of care. The patient did have a diagnosis of opioid use disorder. He was not yet receiving medication-assisted treatment during the dates of service in question, though had indicated interest in this treatment. The patient was no longer experiencing significant withdrawal symptoms. The patient did note urges to use medications. The treatment plan did not appear to indicate specific strategies for dealing with cravings. The patient did not have serious medical problems that were not stable and continued to be requiring inpatient rehabilitation management. The patient did not have serious psychiatric symptoms that were active during the dates of service in question. The patient was at risk for using substances and hazardous situations. Based on review of the provided criteria, the patient did meet criteria for continued inpatient rehabilitation level of care. The LOCADTR result was Concurrent Review Level of Care: Inpatient Rehabilitation. Therefore, the requested services were medically necessary.