Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Substance abuse inpatient rehabilitation stay
The insurer denied the substance abuse inpatient rehabilitation stay.
The determination is upheld.

The patient is an adult male who presented for inpatient level substance use disorder rehabilitation treatment to address substance use of cannabis (marijuana) and alcohol class substances. The patient had no past history of withdrawal seizures, delirium tremens or severe withdrawal symptoms. He had a history of substance use disorder with alcohol and subsequent use of marijuana, escalating to daily continuous use with subsequent use of three 24-ounce beers and three to four shots daily together with five to six blunts per day. His substance use had resulted in psychosocial problems and concern. He was medically cleared prior to his admission.

The patient had previously engaged in substance use disorder treatment with a relapsing clinical course. His last treatment was a detoxification treatment episode with relapse. There was no history of psychiatric disorder or treatment. He denied suicidal or self-harming behavior.

The patient was motivated for rehabilitation treatment. The patient exhibited limited insight and impaired judgment with questionable control of impulses. There were no severe symptoms on mental status examination; the patient had no symptoms of severe depression, mania, psychosis, perception, cognition, or thought disorder. He denied problems with energy, concentration or appetite though he was dysphoric with insomnia.
He had no acute general medical conditions except for elevated blood pressure with chronic medical conditions including hypertension and hyperlipidemia. He was tobacco dependent at 12 (half) pack per day.
The patient was divorced and housed. There was no report of trauma history or legal issues in this case. He reported having support from family and friends.
The rehabilitation treatment included a focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with recovery groups. The patient engaged in treatment and intensive services, monitoring and structure provided within the inpatient treatment program. The patient participated actively with treatment and showed no significant symptoms or signs of withdrawal or post-acute withdrawal symptoms though he had persistently elevated blood pressure that was a focus of treatment.

The patient readily engaged in rehabilitation treatment and he had no complications other than ongoing concern with the elevations of blood pressure treated with hydrochlorothiazide (HCTZ) and lisinopril. He was fully compliant with his treatment plan and received vitamin supplementation and nicotine replacement therapy, and he had the availability of comfort medications, as well as ongoing treatment for his blood pressure. He was prescribed melatonin for sleep. He was started on gabapentin and naltrexone for medication assisted treatment. He was actively participating in treatment, learning better coping skills and made efforts to develop a relapse prevention plan and sober supports. During the course of treatment, the patient's mood and sleep improved and he gained insight learning coping skills. He had positive interactions with staff and peers. He was discharged with referral for clinically appropriate aftercare and plans for continued medication assisted treatment.

The treatment facility case records and summary, health plan documents, appeal documents, and correspondence from the health plan and treatment facility were reviewed. The rationale for the denial of certification for coverage of the requested treatment was reviewed. This case is a New York State mandated review with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines/Criteria.

The issue under review is the medical necessity of substance abuse inpatient rehabilitation stay.

The requested health service/treatment of substance abuse inpatient rehabilitation stay was not medically necessary for this patient. The proposed inpatient substance use disorder rehabilitation treatment was amenable to treatment at a lower level of care. 
The patient was motivated to actively engage in rehabilitation treatment without biomedical complications other than an elevated blood pressure or significant withdrawal symptoms. He had prior exposure to substance use disorder treatment and was able to engage and participate actively in the treatment plan without complication. There were no psychiatric disturbances or general medical concerns that required inpatient level services, structure or monitoring. The patient was noted to benefit in all aspects of his treatment plan throughout his continued stay. He had a supportive family and access to sober housing from which substance use disorder treatment could be received. Thus, the patient's substance-related treatment and rehabilitation services could have been effectively provided at a lower level of care in a less restrictive treatment setting.
This answer is consistent with prevailing standards of professional practice, the published societal guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as the application of NY State OASAS LOCADTR 3.0 Guidelines/Criteria, referenced below.

The health plan's determination of medical necessity is upheld in whole.