Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Continued residential rehabilitation 

Summary:
The patient is an adult male who presented for substance use disorder residential rehabilitation treatment to address substance use of stimulants (cocaine); cannabis (marijuana); and alcohol. The patient was tobacco dependent; he had no past history of delirium tremens, but was in treatment for seizures, as well as his chronic medical conditions. He had a history of substance use disorder with onset in adolescence, escalating to daily continuous use of cocaine and alcohol and intermittent use of marijuana that resulted in legal, occupational, and other psycho-social problems. He was using $150 worth of cocaine and six to seven beers daily with intermittent use of marijuana. 

The patient had previously engaged in substance use disorder treatment with relapses. He had a history of being incarcerated and had been recently charged with petty larceny with court date pending.

There was a history of psychiatric disorder and treatment as an outpatient for unspecified anxiety and depression, and the patient has trauma history and history of posttraumatic stress disorder (PTSD). 

The patient was motivated for rehabilitation treatment with internal and external factors. The patient exhibited fair, but limited insight and fair judgment and control of impulses except when using. He has a history of using prostitutes and unprotected sex including history of sexually transmitted disease. 

There were no severe symptoms on mental status examination; the patient had no symptoms of mania, psychosis, perception, cognition, or thought disorder. The patient was described as "groomed" and "cooperative" with good eye contact. He was depressed and exhibited anxiety and complained of insomnia. 

The patient had no acute general medical conditions. Chronic conditions included cardiovascular disease and diabetes mellitus and the seizure disorder with associated treatments. Medications included Topamax, Digoxin, Xarelto, lisinopril, spironolactone, Metformin, and diltiazem. 

The continued substance abuse rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was motivated and able to effectively engage in rehabilitation services, and, the patient did not need the continued structure or monitoring of an inpatient residential setting or 24-hour monitoring in order to safely and effectively participate in continued rehabilitation substance use disorder rehabilitation treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms in this case that would have required continued residential level services and rehabilitation treatment. Moreover, the patient had support for the substance use disorder treatment with access to sober housing and peer support, and he was motivated to participate in rehabilitation treatment, as noted. Thus the requested benefit of residential rehabilitation services was not medically necessary.

This answer is consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, as well as New York State instruction regarding medical necessity reviews and the application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.