Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorder.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The case involves a female who self-referred to inpatient rehabilitation and substance use disorder treatment to address a longstanding history of severe substance use disorder with alcohol. The patient has no history of withdrawal seizures or delirium tremens. She had past treatment experience with at least three detoxification episodes, but no prior rehabilitation treatment episodes. Her substance use included one pint of liquor daily, and her drug screen was positive for benzodiazepines and opiates; she also had a history of cannabis use disorder that was in remission.

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. She was noted to participate in the therapeutic activities, was social with peers and was actively participating in recovery groups, and, 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. She was sleeping and eating okay with steady gait, and functioning well with daily activities.

Throughout her brief inpatient stay, the patient remained stable and engaged with the treatment regimen. She received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged after completing the treatment episode with recommendations for clinically appropriate outpatient aftercare, and recommendation for follow up with a primary care physician. 

The Issue Under Review is the Inpatient Rehabilitation Services.  The denial reason 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 or psychiatric comorbidity and had family support for her effort at substance use disorder treatment.  The appeal was on the basis of multiple past treatment episodes with no "clean" time, 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 is not medically necessary for this patient.
The patient received inpatient level rehabilitation treatment. She self-referred for treatment with family support and had not previously received rehabilitation treatment, having only received detoxification treatments with relapses. As the health plan asserts, the patient had no significant general medical or psychiatric comorbidity and had family support for her effort at substance use disorder treatment. She readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. 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 brief inpatient stay, 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 is not consistent with Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria and medical necessity for the inpatient level treatment 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.

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. She did not need the monitoring or the structure of an inpatient setting in order to receive effective substance use disorder rehabilitation treatment. Moreover, she was motivated for treatment with family support and she readily engaged with treatment and was involved with treatment interventions and peer-supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports. Thus, the health plan's determination is reasonable in this case scenario, as 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.