Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse disorder
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a male who presented for inpatient substance use disorder rehabilitation treatment to address substance use of alcohol. The patient was also tobacco dependent at one pack per day use for forty years. He had no past history of delirium tremens or withdrawal seizures, but had chronic medical conditions including hypertension and asthma and history of a left-sided stroke (cerebral vascular accident [CVA]). He had a history of substance use disorder with onset in adolescence, escalating to daily continuous use of approximately one pint of alcohol per day.

The patient had previously engaged in substance use disorder treatment with relapses. He had a history of at least 27 previous detoxification treatments, and he had at least one admission for rehabilitation treatment that lasted one day.

There was a history of psychiatric disorder and treatment as an outpatient for unspecified anxiety and depression. He denied history of psychiatric hospitalization or suicidal or self-harming behavior. 

The patient was motivated for rehabilitation treatment. The patient exhibited fair, but limited insight and fair judgment and control of impulses. 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 euthymic and exhibited anxiety and complained of insomnia. 

The patient was single and lived with his significant other who was sober. He was unemployed and a veteran. There was a family history of substance use disorder reflecting genetic predisposition. He had trauma/abuse history as a child and denied any legal issues.

The rehabilitation treatment included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and, involvement with 12-step recovery groups. The patient engaged in treatment and intensive services, sober housing, monitoring, and structure provided within the inpatient rehabilitation treatment program. The patient participated actively with treatment, and showed no significant symptoms or signs of withdrawal, and had no complications of rehabilitation treatment. The patient participated in activity therapies and other therapeutic interventions to improve insight and life skills. He received vitamins and supplements, and medications that included clonidine and hydrochlorothiazide (HCTZ). His blood pressure was mildly elevated during his brief stay. He was discharged with transfer to a sister rehabilitation facility with plans for continued substance use disorder treatment.

No, the proposed treatment of inpatient admission was not medically necessary for this patient.

The substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was generally motivated and able to effectively engage in rehabilitation services. The patient's clinical features and treatment needs did not warrant the structure or monitoring of an inpatient level setting or 24-hour monitoring in order to safely and effectively participate in rehabilitation substance use disorder rehabilitation treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms in this case that would have required inpatient level structure, monitoring or the intensity of inpatient level services. Moreover, the patient had support for the substance use disorder treatment with access to sober housing with his significant other and the availability of peer support, and the patient was motivated to participate in rehabilitation treatment, as noted. Thus, the requested benefit of inpatient admission was not medically necessary for this patient.

This answer is consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (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.

The patient was generally motivated to actively engage in rehabilitation treatment without biomedical complications or significant withdrawal symptoms. He had prior exposure to substance use disorder treatment, and he was able to engage and participate actively in the treatment plan without complication. There were no severe psychiatric disturbances or general medical concerns that required inpatient level services, structure or monitoring, as noted above. The patient was noted to benefit in all aspects of his treatment plan throughout his stay. Thus, the patient's substance use disorder rehabilitation treatment could have been effectively provided at a lower level of care including sober housing, and other supportive services including peer support through 12-step recovery groups such as Alcoholics Anonymous (AA) and/or the consideration of medication assisted treatment. Moreover, the application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines does not support the admission or continued treatment at the inpatient level of care, as the health plan asserts.