Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Substance Abuse Inpatient Rehabilitation
The insurer denied the substance abuse inpatient rehabilitation.
The health plan's determination is upheld.

The patient is a male who was admitted to inpatient level services for the treatment of hallucinogens (phencyclidine [PCP]), cocaine and alcohol use disorders. The patient had been using PCP up to six times per week and crack cocaine daily together with the intermittent use of up to one pint of alcohol. The patient is self-referred for substance-related treatment in the context of severe psychosocial stressors. The patient has no acute general medical issues. The medical screening was negative and unremarkable except for a positive drug screen consistent with his history. He was tobacco/nicotine dependent with light use.

There are co-occurring psychiatric disorders in this case including post-traumatic stress disorder (PTSD) and unspecified anxiety and depressive disorders with no current symptoms or treatment for these conditions. The patient is unemployed and homeless and he is not living in a shelter. There is a report of an unspecified trauma history in this case, including childhood abuse and domestic violence as an adult. There are no legal issues in this case.

The patient engaged in substance use disorder treatment with active involvement in group and educational sessions, as well as other therapeutic interventions to support healthy living and the development of sober supports. The patient was noted to adjust easily to the treatment program. In this regard, the patient worked on coping skills and a relapse prevention plan with the identification of triggers including peer support to address the negative influence of the social environment. The patient remained engaged during the brief inpatient stay with satisfactory progress. However, the patient was discharged against medical advice with the recommendation for clinically appropriate aftercare.

The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment can be/could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that inpatient level structure and 24-hour nursing monitoring is medically necessary for a successful outcome.

The requested health service/treatment of inpatient rehabilitation was not medically necessary for the patient. The Mental Status Examination revealed no severe symptoms and the patient was cooperative and dysphoric with normal speech, linear thought processing, and no disturbance of thought content such as paranoid thoughts or delusions. He lacked coping skills and demonstrated only fair insight. He reported urges to use PCP and cocaine and had post-acute withdrawal symptoms of restlessness, anxiety, and depression. He had been unable to cut down on his own. He was noted to have deficient coping skills and needed to identify triggers for his substance use.

The inpatient level substance disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, education and attendance at self-help recovery groups with peer support. Comfort medications were available as needed, and he was prescribed vitamins and he had the availability of a nicotine replacement. 

The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was able to effectively engage in rehabilitation services, and the patient did not need the structure or 24-hour nursing monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment.