Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance use disorder.
Treatment: Inpatient Rehabilitation Admission.
The insurer denied the inpatient rehabilitation admission. 
The denial is upheld.

The patient is a adult male self-referred with encouragement from family and friends for inpatient rehabilitation and substance use disorder treatment. The patient has a history of longstanding substance use disorders with alcohol and stimulant (cocaine) class substances with onset in adolescence. More recently he had used heroin and/or Suboxone obtained on the street. The patient has no history of withdrawal seizures or delirium tremens. He was referred due to difficulty with the social environment and coping problems related to the substance use disorders which constituted a violation of his parole status. His history of substance use included up to three 24-ounce beers and $100 worth of cocaine on a daily continuous basis. He had also used heroin most recently and indicating that this was a major concern.

Upon admission to inpatient level services, the patient received comprehensive evaluation and 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, as well as participation in 12-step recovery groups and other therapeutic activities. 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 placed on clear liquids and treated with Reglan for the GI (gastrointestinal) upset which resolved by the second week of 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 PRN (as needed) Vistaril, as well as comfort medications.

Throughout his inpatient stay, the patient remained stable with mental status and engaged with the treatment regimen, as noted. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged with plans for clinically appropriate aftercare of his substance use disorders with referral for outpatient services and return home.

The health plan denied coverage of the admission on the basis of NYS (New York State) OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria indicating that there were no acute symptoms that would have required inpatient level services and suggesting that residential level treatment was the appropriate level of care.

The treatment facility appealed on the basis of NYS OASAS LOCADTR 3.0 Criteria indicating that inpatient level treatment was the appropriate level of care, as the patient lacked coping skills and needed to work on a relapse prevention plan with identification of triggers.

No, the requested inpatient rehabilitation admission 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 GI (gastrointestinal) upset that responded to treatment and with 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.

The application of NYS OASAS LOCADTR 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting, also as the health plan asserts. Thus, medical necessity for the inpatient substance use rehabilitation treatment for the admission is not met in this case scenario, consistent with ASAM (American Society of Addiction Medicine) Criteria, the scientific literature and published guidelines, referenced below, and with the application of NYS OASAS LOCADTR 3.0 Criteria.

Yes, the health plan has acted reasonably, with sound medical judgment, and in the best interest of the patient.

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review. The patient had presented with a level of medical stability and no co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care. He did not need the monitoring or the structure of an inpatient setting to receive effective substance use disorder treatment, as the health plan asserts. He readily engaged with treatment and was involved with treatment interventions and peer-supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports or living. Thus, the health plan's determination is reasonable in this case scenario.

This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of NYS OASAS LOCADTR 3.0 Guidelines.