Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient Rehabilitation Treatment Admission
The insurer denied: Inpatient Rehabilitation Treatment Admission
The denial is upheld.

The patient is an adult female who received detoxification treatment and was referred for inpatient rehabilitation substance use disorder treatment. Her history of substance use included use of up to two pints of vodka per day, $100 worth of crack cocaine per day, and one to two blunts of marijuana per day. The patient was self-referred and indicated that she was tired of feeling unwell. She had an extensive history of detoxification treatments and rehabilitation treatment with relapses. Chronic conditions included chronic obstructive pulmonary disease (COPD) with asthma, lower back pain and arthritis, dyspepsia treated with Pepcid, and history of syphilis with treatment and cerebral vascular accident (CVA) without sequelae. The patient is married and unemployed with disability and domiciled in a shelter for at least the past two years prior to admission. She has children with support from the youngest daughter who was a motivating factor. Upon admission to inpatient level services, the patient received comprehensive evaluation and treatment. The patient was noted to be engaged in the therapeutic activities, social with peers and participating in recovery groups and most other group sessions, and, adherent with medication. She continued to receive intensive rehabilitation services, monitoring, and structure including 24-hour nursing monitoring and was discharged after 23 days with referral for clinically appropriate care of the mental health and substance use disorders, as well as arrangements for general medical care. Denial of coverage is based on New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and medical necessity indicating that there were no general medical or psychiatric issues warranting 24-hour nursing care and that treatment could have been provided in a less restrictive treatment setting. The appeal was on the basis of the clinical features and treatment dimensions with reference to the psychosocial stressors and lack of coping skills with no stability or structure or sober supports warranting the inpatient level rehabilitation treatment. 

The proposed treatment was not medically necessary.

The health plan's determination is appropriate in keeping with New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and prevailing standards of medical practice. 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 disorders, diagnosed with alcohol, cannabis, and stimulant/cocaine use disorders. She received inpatient level rehabilitation treatment and readily engaged in treatment and had no significant biomedical (withdrawal symptoms or signs) or psychiatric treatment issues. 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 her 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 New York 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 the Level of Care Utilization System (LOCUS) and the American Society for 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.