Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male. He self-referred 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 prior treatments, including medication-assisted treatment with a relapsing course, and more severe use in the three years prior to admission. Drug screen was consistent with history and positive for cocaine. He reported high-risk use, which included driving while under the influence of alcohol and drugs. The patient's evaluation on admission revealed a mental status examination that reflected reasonable motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. There were no significant withdrawal symptoms or post-acute withdrawal symptoms though he displayed anxiety and motor agitation. He also reported insomnia. 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 recovery groups and other therapeutic activities. The patient engaged in substance use disorder rehabilitation treatment. He was noted to be engaged in the therapeutic activities, social with peers, and participating in recovery groups. He resumed medication assisted treatment with Vivitrol. Throughout his inpatient stay, the patient remained stable with mental status and had engaged with the treatment regimen, as noted. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour nursing monitoring. The patient was discharged on day #22 with plans for clinically appropriate aftercare of his substance use disorders with referral for outpatient level treatment and recommendation for involvement in 12-step recovery groups with obtainment of a sponsor, as well as continued use of Vivitrol.

The Inpatient Rehabilitation Admission was not medically necessary.

The patient presented with substance use disorders and was diagnosed with alcohol and stimulant/cocaine use disorders. He 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 anxiety 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 or structure or 24-hour nursing monitoring, as the health plan asserts. The application of NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 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. Thus, medical necessity for the Inpatient substance use rehabilitation treatment for the requested dates of service is not met in this case scenario, consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature, and published guidelines, referenced below, and with the required application of New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3.0 Criteria. Therefore, the requested Inpatient substance-related rehabilitation treatment was not medically necessary for this patient.