Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polysubstance Abuse.
Treatment: Continued Residential Substance Use Treatment.
The insurer denied the Continued Residential Substance Use Treatment.
The denial is upheld.

The patient is an adult male referred for residential substance use disorder rehabilitation services in order to address severe polysubstance use disorder with opioid (heroin and Fentanyl), stimulant (cocaine), sedative-hypnotic anxiolytic (benzodiazepine) and tobacco class substance use disorders. His substance use had escalated over several years after a relapse to continuous daily use in the context of severe stressors including loss of employment and housing, and a decline in functioning. The patient had previously received formal substance use disorder treatment without sustained sobriety or abstinence and relapse ten years prior to admission. He did not have a history of seizures or delirium tremens or other severe withdrawal issues in the past.

The patient has a history of significant psychiatric disorders including major depressive disorder and attention deficit hyperactivity disorder (ADHD) and posttraumatic stress disorder (PTSD). He denied history of psychiatric hospitalization or suicidal behavior. 

There were no acute general medical conditions that were a focus of treatment; he has a history of chronic back pain occurring after falling from a ladder. He was medically screened and had an intake prior to the admission for residential rehabilitation treatment. 

The patient is divorced and separated from a significant other, and unemployed and homeless with limited family support and sober supports that were not working. There is legal history of incarceration and parole for drug-related crime. He reported trauma-related problems best characterized as unspecified and persistent or chronic.

Mental status examination revealed no evidence for severe cognitive impairment, psychosis, dissociation, perceptual disturbance or thought disorder. Insight and judgment were limited and impaired due to the substance use with high risk for relapse due to the recovery environment and lack of coping skills necessary for a recovery effort. He exhibited symptoms of anxiety with dysphoric mood. He denied suicidal and homicidal ideation. He did not have significant drug withdrawal symptoms or post-acute withdrawal symptoms as he presented for residential level treatment. However, he had intense craving despite receiving medication assisted treatment with Suboxone.

The patient was admitted to residential level rehabilitation services. The patient engaged superficially in substance use disorder treatment including group and milieu interventions, as well as educational sessions. He had the opportunity to participate in recovery groups with peer support. Psychiatric management was provided with use of lithium and the subsequent addition of Adderall at 300 and 20 milligrams (mg) per day respectively, as well as medication assisted treatment with Suboxone at 16 milligrams per day. The patient gradually engaged in treatment that included evidence-based psychosocial interventions-dialectical behavioral therapy (DBT) and Seeking Safety and therapist-led recovery groups. Case management worked to include his significant other and/or ex-spouse in the treatment for support, as well as addressing psychosocial needs with housing and vocational supports. 

The patient was engaged in treatment and committed to a recovery process. He was calm and cooperative and groomed/kempt. His mood had improved and his concentration was better, with improved motivation. He gained insight together with better judgment. He was medication adherent with tolerability. Continued rehabilitation treatment was being planned to include continued focus on coping skills, relapse prevention with identification of triggers, education about the disease model of addiction, and, active involvement with recovery groups, as well as other interventions to support a recovery effort. And, the patient had no complications with treatment and no safety concerns. He was noted to have control of impulses and had not shown severe psychiatric symptoms.

No, the proposed treatment, continued residential substance use disorder treatment is not medically necessary for this patient.

The residential substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was motivated and able to effectively remain engaged in rehabilitation services, and, the patient did not need the structure or 24-hour monitoring of a residential setting in order to safely and effectively participate in continued rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted continued residential level services and treatment. Moreover, the patient demonstrated his motivation for continued involvement in the substance use disorder treatment, as noted above. Thus, the requested benefit of continued residential substance use disorder treatment was not medically necessary for this patient.

This answer is consistent with prevailing standards of professional practice, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews together with 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.

The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment can be/could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports and supported housing. There is no evidence that residential level structure and 24-hour monitoring is medically necessary for a successful outcome with regard to the dates of service.  And, there were no biomedical, psychiatric or general medical issues that warranted the continued inpatient level treatment in this case scenario.

Thus, as the health plan asserts, the patient's substance use disorders and co-occurring psychiatric disorders were amenable to treatment at a lower level of care in this case scenario, and the health plan's determination of medical necessity was consistent with the application of NY State NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, referenced below, as well as American Society of Addiction Medicine (ASAM) Patient Placement Criteria and the scientific literature and published guidelines, also referenced below.