Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient Rehabilitation Services.
The insurer denied Inpatient Rehabilitation Services.
The denial is upheld.

The patient is an adult male. He presented with a request for readmission to detoxification services with return to the program after leaving the
program and discharge against medical advice. He had been receiving
detoxification with a methadone protocol. The patient was using opioid (heroin),
alcohol and cannabis class substances on a continuous daily basis. He presented
with a blood alcohol level of zero and mild symptoms of withdrawal.

The patient had received past substance use disorder treatments including the
recent detoxification treatments earlier in the year. The patient provided no history
of withdrawal seizures, delirium tremens or severe alcohol or drug withdrawal
symptoms. The patient had a history of psychiatric disorders that included
unspecified anxiety and depressive disorders, as well as chronic insomnia. He was not receiving treatment with psychotropic medications. He had no acute or chronic general medical problems; he was tobacco dependent at one-quarter pack per day for five years. His substance use included up to 10 bags of heroin with intranasal administration (snorting), two 24-ounce beers and one marijuana blunt on a daily continuous basis.

The patient received a drug screen that was positive for methadone as expected
and was admitted for continued inpatient level detoxification with plans for step
down to rehabilitation substance use disorder treatment at the time of completion.
Vitamin replacement therapy and comfort medications were continued including
clonidine and Benadryl. His laboratory assessment had been normal or
unremarkable as well as his physical examination that was consistent with history.

On mental status examination, there were no severe symptoms such as thought
disorder, cognitive impairment, severe mood disturbance, psychosis or perceptual
disturbance, or suicidal ideation. The patient reported nausea and vomiting and
light-headedness, but no other somatic complaints. Vital signs were normal.
The evening following re-admission the patient was noted to be acting strange and
erratic and was thought to be under the influence of an unknown substance.
Emergency medical services were summoned, and he was discharged with transfer
to another facility for evaluation and treatment. He was discharged from the
program early the morning after admission.

No, the Inpatient Admission was not medically necessary for the patient.

The proposed inpatient stay was not medically necessary in keeping with NY (New
York) State LOCADTR (level of care for alcohol and drug treatment referral) Criteria
in that the patient did not present with significant drug or alcohol withdrawal
symptoms having just received detoxification treatment with discharge the same
day as his presentation. The patient's substance use disorder did not require the
structure of an inpatient setting or 24-hour monitoring. The patient displayed no
serious disturbance of mental status despite having a history of ongoing substance
use disorder. There was no co-occurring psychiatric disorder or psychiatric
symptoms that would have warranted the re-admission for acute inpatient level
treatment. Moreover, the patient did not show evidence for suicidal or aggressive
behavior or risk, or severe cognitive impairment or psychosis, or perceptual
disturbance, or other emotional disturbances that would have warranted an
inpatient level admission and treatment. There were no severe symptoms of
withdrawal or biomedical issues in this case at the time of re-admission, and the
patient had received detoxification treatment and rehabilitation substance use
treatment recently, as noted in the clinical summary. Moreover, the patient needed
emergency medical services and could have been effectively managed in an
emergency department with a clinically appropriate discharge plan and disposition.
The patient had a working knowledge of substance use disorder treatment with a
past history of multiple treatment episodes. Thus, the inpatient admission and the
requested inpatient level services were not medically necessary in this case
scenario.

This answer is consistent with New York State OASAS (Office of Addiction Services
and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0
Criteria and with established practice guidelines, the scientific literature, and ASAM
(American Society of Addiction Medicine) Criteria, as referenced below.
In this case scenario, the patient was amenable to treatment with lower level care
in a less restrictive setting. His general medical needs could have been addressed
with emergency medical services which did occur shortly after his admission. The
patient displayed no serious disturbance of mental status at the time of admission and did not warrant re-admission to acute inpatient level care. Moreover, the patient
did not show evidence for suicidal or aggressive behavior or risk, or severe
cognitive impairment or psychosis, or perceptual disturbance that would have
warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case that would have required inpatient monitoring or services. Moreover, the patient was suspected to be intoxicated and under the influence of an unknown substance that warranted evaluation and treatment in an emergency department setting. The Inpatient Admission was therefore not medically necessary in this case scenario, as the health plan asserts. NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria/Guidelines are not met for the inpatient level of care, as referenced below.