Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Rehabilitation Service
The insurer denied the Inpatient Rehabilitation Service.
The denial is upheld.

The case involves an adult male medically screened and admitted for inpatient rehabilitation substance use disorder treatment in order to address use of stimulant (cocaine) and cannabis (marijuana) class substances with a history of alcohol use disorder in full remission. The patient has no reported history of withdrawal seizures or delirium tremens, or severe withdrawal symptoms. His history of substance use included use of up to one gram of crack cocaine daily and intermittent use of marijuana. The patient has a history one or more prior treatment episodes with relapse.

The patient has no history of psychiatric disorder, or suicidal behavior or psychiatric hospitalization. The patient had no acute general medical issues other than dental pain; he was medically screened upon admission including laboratory testing that was normal or unremarkable and drug screening that was positive for cocaine and tetrahydrocannabinol (THC). He was tobacco dependent.

The patient is single and homeless and lives in a shelter with peers using drugs. 

He was diagnosed with a mood disorder in addition to the substance use disorders.

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 groups and other therapeutic activities within the treatment milieu. 

The patient readily engaged in substance use disorder rehabilitation treatment. He actively received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. His clinical course was complicated with persistent dental pain that resulted in his discharge against medical advice with referral for dental services and recommendations and referrals for continued and clinically appropriate aftercare of the substance use disorders.

The issue under review is inpatient substance use disorder rehabilitation treatment.

The health plan denial was on the basis of the New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 criteria/guidelines indicating that the criteria for inpatient level treatment was not met. Additionally, the health plan noted no general medical or psychiatric symptoms or issues that warranted inpatient level care indicating that the patient could have been safely and effectively treated in a less restrictive treatment setting with lower-level care such as partial hospital program (PHP) level care.

In the appeal, the treatment facility asserted that Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) criteria were met on the basis of the longstanding use of multiple substances and the patient's need for monitoring and the structure of an inpatient rehabilitation setting. The appeal referenced the patient's adverse living situation, lack of support, high risk for relapse and the presence of drug dreams and craving.

The proposed treatment and the requested benefit of inpatient substance abuse rehabilitation treatment was not medically necessary.

The application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 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 asserted. Thus, medical necessity for the inpatient rehabilitation substance use disorder treatment is not met. This answer is consistent with the American Society of Addiction Medicine (ASAM) criteria.