Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Substance Use Inpatient Rehabilitation Treatment
The insurer denied the substance use inpatient rehabilitation treatment.
The denial is upheld.

The patient is an adult male self-referred for inpatient rehabilitation and substance use disorder treatment following detoxification treatment. The patient has longstanding substance use disorders with alcohol and stimulant (cocaine) and opioid (heroin) class substances with onset in adolescence. The patient has no history of withdrawal seizures or delirium tremens but did report frequent blackouts. His history of substance use included up to one-half pints of liquor twice a week together with $100 worth of crack cocaine and 2 to 3 bags of heroin with intranasal administration on a daily continuous basis. The patient had an extensive history of substance use disorder treatments with detoxifications and rehabilitation treatment. He was receiving medication-assisted treatment with methadone at 60 mg (milligrams) daily. He was tobacco dependent at one-fourth pack per day.

The patient is unemployed and homeless living in a shelter for the past two years. 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 participation in peer-supported recovery groups and other therapeutic activities. The patient engaged in substance use disorder rehabilitation treatment. He was noted to be engaged in the therapeutic activities, social with peers, and participating in recovery groups. He was prescribed his usual dose of methadone.

Throughout his brief inpatient stay, the patient remained stable with mental status and remained engaged with the treatment regimen. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The patient was discharged against medical advice with plans for clinically appropriate aftercare of his substance use disorders and referral back to the methadone clinic.

The health plan denied coverage of the request on the basis of NYS (New York State) OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) 3 Criteria, indicating that there were no acute psychiatric or general medical problems that would have required inpatient level services.
The treatment facility appealed based on NYS OASAS LOCADTR 3 Criteria, indicating that inpatient level treatment was the appropriate level of care.

The requested substance use inpatient rehabilitation treatment was not medically necessary.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine and opioid and tobacco use disorders. He self-referred following detoxification treatment and received inpatient level rehabilitation treatment. He readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring, as the health plan asserts.

The application of NYS OASAS LOCADTR 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting, also as the health plan asserts.