Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Substance Abuse.
Treatment: Inpatient Detoxication Admission.
The insurer denied the Inpatient Detoxication Admission.
The denial is overturned, in part.

The patient is an adult male referred for substance use disorder treatment to address severe alcohol use disorder. The patient had recent substance use disorder treatment in the month and the week prior to his presentation with immediate relapses. His substance use history began in adolescence with escalating use of alcohol and subsequent use of cocaine in combination with opioids. He had stopped using opioids (remission) and used one hit of cocaine intermittently with inhalation. He was using up to three pints of alcohol daily with a history of legal complications and past history of incarceration. He had motivating factors related to psychosocial stressors involving primary support, occupational, social environment and legal domains including an upcoming court date for "drinking related problems."

The patient's treatment included intensive services, sober housing, monitoring, and structure provided within the treatment program. The patient participated in milieu activities designed to support sober living and life skills. He struggled to engage in a recovery process and was anxious with ambivalence towards maintaining abstinence due to craving in the context of a history of leaving against medical advice (AMA) and administrative discharges from past treatment. He was prescribed buspirone and trazodone to address anxiety and insomnia, as well as other sleep aids, vitamins, nicotine replacement for tobacco dependence, and comfort medications. 

The patient was noted to have no residual post-acute withdrawal symptoms. He remained anxious, but less so with improved sleep. He was participating in groups and educational sessions, and 12-step recovery groups, as well as other therapeutic interventions to improve motivation and coping skills. He declined medication assisted treatment. The patient had worked on coping skills and identification of triggers, and had shown diminished anxiety, and fair insight and judgement with better sleep and functioning. He was medication adherent with tolerability. His treatment plan indicated focus on coping skills and consideration of a relapse prevention plan upon return to the community. He continued with sub-acute level treatment with step down to a crisis center with plans for extended treatment and sober living and continued involvement with 12-step recovery groups and obtainment of a sponsor, as well as plans to seek employment.

The issue under review is inpatient residential (sub-acute level) substance use disorders treatment.

The health plan denied the requested treatment 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 criteria were not met and that outpatient level care was appropriate.

Yes, in part; the first portion of the admission dates in question, the proposed treatment was medically necessary for this patient; however, the proposed treatment for the latter half of the admission dates in question was not medically necessary in this case scenario.

No, in part; the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient; however, the latter portion of the dates of admission in question, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
As indicated above, the proposed services were warranted and medically necessary for a portion of the admission dates in question, and were not medically necessary for the latter portion including the application of New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria. The patient could have been effectively managed with lower level care in a less restrictive treatment setting for the remaining dates of service in question.

The patient needed the admission and continued structure and monitoring of an inpatient residential service for the dates of service in order to effectively address the risk of relapse, continue to learn adequate coping skills to remain engaged in rehabilitation treatment, to address psychosocial issues pertinent to his substance use disorders including the need for sober supports, and develop a transition plan that would effectively prevent treatment failure. 

The patient remained at high risk for relapse during this time frame with active symptoms of anxiety requiring medication management with clinically appropriate monitoring. Moreover, the patient continued to struggle with readiness to change and remain abstinent, and, he initially had intense craving and other symptoms reflecting post-acute withdrawal symptoms that did necessitate the admission and continued structure and monitoring of an inpatient residential setting while considering the use of anti-craving medication and additional medications to address anxiety and insomnia. The patient's lack of awareness or limitations of insight and impulse control, together with the seriousness of his substance use disorder with combined stimulant and alcohol class agents is illustrated by his behavioral disturbances and deterioration in functioning with continued substance abuse, despite having access to treatment in the community. The psychiatric co-morbidity (anxiety disorder) initially complicated this case, as the patient had symptoms of anxiety that were triggering the substance abuse, as well as impulsivity related to the quantity of substances used, and lack of sober supports and a sober recovery environment. These clinical features and treatment dimensions support the assertion that the patient could not have been effectively treated at a lower level of care consistent with the American Society of Addiction Medicine (ASAM) Criteria and the appropriate application of New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria. Therefore, these clinical factors needed to be effectively addressed with intensive services and monitoring in an inpatient residential (sub-acute) treatment setting, prior to step down to a lower level of care.

However, the sub-acute inpatient residential level substance-related treatment and services for the latter portion of the admission dates in question were amenable to treatment at a lower level of care and therefore not medically necessary. During this time interval the patient had effectively engaged in rehabilitation treatment, and the patient's co-occurring psychiatric disorder (unspecified anxiety disorder with insomnia) had been addressed with stabilization; and, the patient was able to effectively participate in rehabilitation services with steady progress, as well as consideration of transition to sober living with continued rehabilitation treatment. The patient did not need the continued structure or monitoring of an inpatient residential setting in order to effectively continue rehabilitation treatment and services. These services could have been provided at a lower level of care with sober supports and continued involvement in rehabilitation treatment, as well as treatment for the co-occurring psychiatric condition.

The requested services for the latter portion of the admission dates in question are not consistent with prevailing standards of professional practice, or consistent with published practice guidelines (best practice) or the American Society of Addiction Medicine (ASAM) Criteria, referenced below, as well as New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria.