Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male referred for inpatient rehabilitation substance use disorder treatment in order to address use of a cannabis class substance with use of two to three joints per day. The patient has no reported history of withdrawal seizures or delirium. The patient was self-referred and indicated that he was tired of feeling unwell.

The patient has a history of psychiatric disorder and treatment for schizoaffective disorder, bipolar type and comorbid anxiety disorder. The patient has a history of psychiatric hospitalizations with ongoing outpatient treatment with clozapine and Haldol Decanoate and Depakote. There is a history of formal substance use disorder treatment with no evidence for outpatient follow up or involvement with 12-step recovery groups.

There were no acute general medical issues and he was medically screened prior to admission. Vital signs were normal and laboratory assessments were normal or unremarkable with a drug screen consistent with history.

Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. The patient was described as cooperative with fluent speech and disorganized thought processing with referential thought content that was bizarre. Mood was anxious and congruent affect. He had no severe symptoms such as mania, psychosis, perceptual disturbance or severe cognitive impairment. He did not report suicidal ideation or aggressive impulses. Sleep and appetite were okay.

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 peer supported recovery meetings, and other therapeutic activities within the treatment milieu. Psychiatric evaluation was provided and he was continued on his psychotropic regimen. Other medications included lisinopril, metformin, Lipitor and alogliptin, as well as a rescue inhaler to address chronic medical conditions.

No, the proposed Inpatient Admission was not medically necessary for this patient.
The health plan's determination is appropriate in keeping with NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria. In this case, the patient could have been reasonably managed with lower-level care in a less restrictive treatment setting. The patient presented with substance use disorder, diagnosed with cannabis use disorder. He was medically screened and had no acute general medical issues. He received inpatient level rehabilitation treatment and readily engaged in treatment and had no significant biomedical (withdrawal symptoms or signs) or psychiatric treatment issues and resumed treatment for the co-occurring psychiatric disorders. During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues or safety concerns that would have warranted inpatient level of care, structure or 24-hour monitoring for the time interval under review. The application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, as well as Level of Care Utilization System (LOCUS) and American Society of Addiction Medicine (ASAM) Criteria referenced below, did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting, as the health plan asserts, and contrary to the appeal indicating that the health plan's rationale for denial was "invalid." Thus, medical necessity for the admission and continued inpatient level substance use disorder services is not met in this case scenario, also consistent with the scientific literature and published guidelines, referenced below, as well as prevailing standards of medical practice.