Appeal type: Medical necessity
Decision: Upheld

Dx: Substance Use/Addiction
Tx: Substance Abuse: Inpatient
Denied: Substance Abuse: Inpatient
Denial UPHELD in whole

The patient is a male who presented for inpatient rehabilitation substance use disorder treatment to address substance use disorder with alcohol class substance of abuse. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a ten year history of alcohol use. His referral to inpatient level treatment was mandated by his parole officer in lieu of incarceration for violation of his parole. He reported intermittent use of alcohol with up to pint of tequila up to three times per month. At the time of her presentation, the patient was not involved in any formal substance-related treatments or self-help recovery groups. He had no history of substance-related rehabilitation treatment.
The patient has no history of psychiatric disorder and no history of psychiatric hospitalization, or suicidal, or self-harming behaviors.
There were no acute general medical issues in this case. The patient had been medically screened at the time of admission. The patient was tobacco dependent; he did not use other substances of abuse.
Evaluation on admission for inpatient level services revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for rehabilitation treatment and had psychosocial support from family with whom he lived. The patient was described as cooperative with fluent speech and linear thought processing with a hopeful outlook. He had no evidence of acute mania, thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. He did not report suicidal or homicidal ideation. There were no somatic complaints, and no evidence of post-acute withdrawal symptoms.
The patient is unemployed and lives with family. He had limited coping skills. There were legal issues with history of ten arrests and one conviction for burglary with prison time and probationary status. He reported trauma history with emotional abuse while in prison.
The patient was admitted to inpatient rehabilitation. His last use of alcohol was several days prior, and he had no withdrawal symptoms. He was provided comprehensive rehabilitation 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 and individual therapy, as well as 12-step recovery groups and other therapeutic activities to enhance motivation to engage in a recovery effort. Psychiatric evaluation was provided, and the consultant confirmed that no co-occurring psychiatric disorder was present.
Throughout the inpatient stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the inpatient treatment program. The patient was participating actively in treatment with continued risk for relapse; the patient had no post-acute withdrawal symptoms, as noted; and, he had no complications with respect to biomedical, general medical, emotional or other treatment domains. Mental status examinations/progress notes reflected sleep, appetite and energy that were okay. The patient continued to make satisfactory progress and was discharged with clinically appropriate aftercare and recommendations to continue involvement in recovery groups and return home while participating in outpatient treatments. Additionally, his parole officer was informed of the patient's satisfactory completion of the mandated inpatient substance use disorder rehabilitation program.
The subject under review is the medical necessity for the inpatient substance use rehabilitation treatment. 

The health plan's determination is upheld.

The requested benefit and service/treatment with inpatient substance use disorder rehabilitation services for the DOS requested is not medically necessary for this patient. The patient presented with alcohol use disorder with the request for treatment that was mandated by his parole officer. He was admitted and received inpatient level rehabilitation treatment as mandated by his parole officer. He readily engaged in treatment with evidence-based psychosocial treatments. During the time interval under review, the patient was noted to be in no apparent distress with satisfactory functioning and active participation in treatment including positive interactions with staff and peers. Throughout his stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care. The application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 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 Inpatient stay through discharge is not met in this case scenario consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.