Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorder 
Treatment: Substance Use-Inpatient Rehabilitation Treatment
The insurer denied: Substance Use-Inpatient Rehabilitation Treatment
The denial is upheld

The patient is an adult male self-referred for inpatient rehabilitation and substance use disorder treatment. The patient has longstanding substance use disorders with alcohol and stimulant (cocaine) and opioid (heroin) class substances with onset in his early twenties. The patient has no history of withdrawal seizures or delirium tremens. His history of substance use included up to one pint of liquor together with one or two 40-ounce beers and $200 worth of crack cocaine and five bags of heroin with intranasal administration on a daily continuous basis. The patient had an extensive history of substance use disorder treatments with detoxifications, outpatient and rehabilitation treatment. Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. Psychiatric evaluation was provided and affirmed that the patient had no co-occurring psychiatric disorders. The patient engaged in substance use disorder rehabilitation treatment. He was noted to be engaged in the therapeutic activities, social with peers, and participating in recovery groups. He was sleeping okay with the use of as needed (PRN) Benadryl as needed, as well as vitamin and nicotine replacement and comfort medications. The patient was discharged against medical advice with plans for clinically appropriate aftercare of his substance use disorders. 

The issue under review is the inpatient substance-related rehabilitation treatment.  The denial was on the basis of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) III Criteria indicating that there were no acute psychiatric or general medical problems that would have required inpatient level services and indicating that the patient's admission was not medically necessary, as treatment could have been provided with lower level care in a less restrictive treatment setting. The treatment facility appealed on the basis of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) III Criteria indicating that inpatient level treatment was the appropriate level of care.

The proposed treatment was not medically necessary for this patient.
The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine and opioid and tobacco use disorders. He self-referred and received inpatient level rehabilitation treatment. He 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 other than gastrointestinal (GI) upset that responded to treatment and he displayed reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring, as the health plan asserts.

Medical necessity for the inpatient substance use rehabilitation treatment is not met in this case, consistent with the American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below, and 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 Criteria.