Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance and alcohol abuse
Treatment: Inpatient substance use rehabilitation treatment
The health plan denied the requested inpatient substance use rehabilitation treatment as not medically necessary.
The health plan's determination is upheld.

This adult male patient was admitted for inpatient substance use disorder rehabilitation treatment to address alcohol, opioid, and stimulant (crack cocaine) class substances of abuse. The patient had no history of withdrawal seizures, delirium tremens, or other episodes of severe withdrawal symptoms. He had a history of substance use disorder with multiple prior detoxification treatments and participation in a methadone maintenance treatment program with continued use of substances. He reported having a daily use of alcohol, heroin and crack cocaine while receiving 55 milligrams (mg) of methadone through the methadone clinic.

The patient has a history of a psychiatric disorder and treatment for bipolar disorder with depression, including history of psychiatric hospitalization. Additionally, the patient reported multiple accidental overdoses.

There were no acute general medical issues in this case; the patient had been medically screened at the time of his admission for substance-related treatments, and generally had normal vital signs and no severe withdrawal or post-acute withdrawal symptoms, though he reported craving and urges to use substances. He was an every-day smoker at one pack per day with 30 pack-years.

Throughout the inpatient stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program. The patient was social with peers and participating actively in treatment with continued risk for relapse; the patient had no severe withdrawal symptoms or post-acute withdrawal symptoms and he had no complications with respect to biomedical, general medical, emotional or other treatment domains. Progress notes reflected stable mood with sleep, appetite, and energy that were okay. He was prescribed Lisinopril, Zyrtec, Lexapro, and low-dose Quetiapine at clinically appropriate dosages with tolerability and positive effect. The patient was discharged against medical advice due to issues with his social security check, but with plans to immediately return to outpatient level treatment with the methadone program and with a recommendation for continued involvement in recovery groups.

The requested health service/treatment of inpatient substance use rehabilitation treatment was not medically necessary for this patient. The patient in this case scenario was not clinically appropriate for the inpatient rehabilitation level of care during the time interval under review. The patient did not need the intensity or duration or 24-hour nursing staff monitoring of an inpatient level of care. The patient was motivated and engaged with treatment and involved with peer supported recovery groups while continuing medication assisted treatment with methadone. Thus, the health plan's determination was reasonable in this scenario. He readily engaged in treatment with continued use of methadone and comfort medications and medications to treat the mood disorder and associated symptoms of anxiety and insomnia. During the time interval under review, the patient was noted to be in no apparent distress with active participation in treatment including positive interactions with staff and peers. There were no treatment issues or biomedical or co-occurring psychiatric disturbances that would have warranted the admission or the continued inpatient level of care.