Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Inpatient Detoxification Admission. 
The insurer denied: Inpatient Detoxification Admission. 
The denial is upheld. 

The case involves an adult male patient. He was medically screened and admitted for inpatient rehabilitation substance use disorder treatment in order to address use of stimulant (cocaine) and cannabis (marijuana) class substances. The patient has no 
reported history of withdrawal seizures or delirium tremens, or severe withdrawal symptoms. The patient has a history of one or more prior treatment episodes with relapse. The patient has a history of psychiatric disorders with diagnoses of bipolar disorder and anxiety disorder with no recent suicidal behavior or psychiatric hospitalization. He was not taking prescribed psychotropic medications that included quetiapine, buspirone, and trazodone. The patient had no acute general medical issues other than ear pain with discharge treated in the emergency department; he was medically screened upon admission including laboratory testing that was normal or unremarkable and drug screening that was positive for cocaine and tetrahydrocannabinol (THC). The patient was single, unemployed, and homeless and lives in a shelter that is drug infested with peers using. The patient has no family supports and indicated that he had significant stress and anger that triggered his substance use. The patient reported a personal emergency that resulted in his discharge against medical advice on day #12 with recommendations and referrals for continued and clinically appropriate aftercare of the substance use disorders to include long-term residential treatment. 

The denial was based on the New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 
Criteria/Guidelines indicating that the criteria for inpatient level treatment was not met. 
The treatment facility asserted that the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria were met based on the longstanding use of multiple substances, comorbidity, and the patient's need for monitoring and the structure of an inpatient rehabilitation setting. The appeal referenced the patient's adverse living situation, lack of support, and high risk for relapse. 

The proposed treatment and the requested benefit of inpatient substance abuse rehabilitation treatment was not medically necessary. 

The patient presented with substance use disorders, diagnosed with cannabis and stimulant/cocaine use disorders. During the time interval under review, the patient was noted to be in no apparent distress other than pain related to an earache, and he 
displayed reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout the 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 nursing 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) 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 asserted. Thus, medical necessity for the inpatient rehabilitation substance use disorder treatment is not met in this case scenario. This answer is consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature, and published guidelines, referenced below.