Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cannabis dependence, substance abuse, alcohol abuse, schizophrenia
Treatment: Substance Abuse Inpatient Rehabilitation Level of Care
The insurer denied the substance abuse inpatient rehabilitation level of care.
The health plan's determination is upheld.

The patient is a male who was admitted to inpatient rehabilitation for the substance use disorder treatment of stimulant (cocaine), alcohol, hallucinogen (phencyclidine [PCP]), and cannabis (marijuana). Despite participating in a court ordered treatment program, the patient was using cocaine intermittently with intranasal administration with daily use of marijuana (one blunt) and PCP and intermittent use of alcohol with four nips up to six times per week. The patient was also tobacco dependent with light use. His referral was prompted by repeated "dirty urines" with a mandate for rehabilitation treatment. He had a history of multiple past substance use disorder treatment episodes with the more recent rehabilitation treatment seven months prior to admission and ongoing outpatient treatment with supervised monitoring with court oversight.

The patient has no acute general medical issues that were a focus of treatment. He did report chronic pain due to dental problems and joint pain. The patient was medically cleared at the time of admission and his laboratory assessment was normal or unremarkable with a positive drug screen for tetrahydrocannabinol (THC) and PCP and cocaine consistent with his history.

There was a co-occurring psychiatric disorder with a diagnosis of schizophrenia. The patient denied suicidal behavior but had a history of at least one psychiatric hospitalization. He was not taking his prescribed Risperidone due to side effects and intolerance.

The mental status examination revealed a cooperative male with clear speech and linear thought processing that was goal directed. The patient's mood was anxious with congruent affect. The patient's thought content included no morbid thoughts. The patient had auditory hallucinations and his insight was limited with impaired judgment due to his addictions. The patient also had sleep disturbance with insomnia.

The inpatient level substance use disorder rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions and recovery groups with peer support. He actively participated in individual, group and educational sessions. He was prescribed Olanzapine titrated to 20 milligrams (mg) together with Trazodone and vitamins with the availability of nicotine replacement therapy throughout his stay. He was also prescribed Bactrim and analgesics and muscle relaxants to address his general medical conditions.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment, and in the best interest of the patient. As the health plan asserts, the patient's alcohol, stimulant (cocaine), hallucinogen (PCP), and cannabis use disorders and co-occurring psychiatric disorder were amenable to treatment at a lower level of care in this case scenario.  

The requested health service/treatment of substance abuse inpatient rehabilitation level of care was not medically necessary for the patient. The structure and intensity of services necessary for the rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. 

The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to receive effective treatment for the co-occurring disorder (schizophrenia).