Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male self-referred and admitted for inpatient rehabilitation and substance use disorder treatment to address use of alcohol and stimulant (cocaine) and cannabis (marijuana and synthetic cannabis) class substances. The patient has no reported history of withdrawal seizures or delirium tremens, but does have a history of blackouts. His history of substance use included use of one 12-pack and one pint of liquor daily together with cocaine administered with inhalation and marijuana or a synthetic cannabis substance. The patient has a history of prior treatment episodes with relapses including rehabilitation treatment a few years prior. He was initially admitted for detoxification treatment with admission/transfer for rehabilitation treatment; his CIWA (clinical institute withdrawal assessment) scale score was 2 on admission with mild tremors and anxiety in the context of normal vital signs.

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. Psychiatric evaluation was provided and he was restarted on quetiapine titrated to 600 mg (milligrams) daily with tolerability, as well as vitamin and nicotine replacement therapy, and amlodipine to address hypertension, and comfort meds.

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. He completed approximately two weeks rehabilitation treatment and was discharged with recommendations and referrals for continued and clinically appropriate aftercare of the mental health, general medical and substance use disorders.

The health plan's denial of coverage was on the basis of the New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 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.

In its appeal, the treatment facility asserted that LOCADTR (level of care for alcohol and drug treatment referral) Criteria were met on the basis of the longstanding use of multiple substances, and the general medical and psychiatric comorbidities that warranted inpatient level of care, as well as a high risk for relapse in this case.

No, the Inpatient Substance Use  Rehabilitation Treatment was not medically necessary.
The patient presented with substance use disorders, diagnosed with alcohol, cannabis and stimulant/cocaine use disorders. He had received a brief detoxification treatment with mild withdrawal symptoms as the health plan noted. The patient was medically screened and had no acute general medical issues or general medical issues that warranted inpatient level care-as the health plan indicated in the denial. The patient readily engaged in treatment and had no biomedical (withdrawal symptoms or signs) or acute psychiatric treatment issues with effective resumption of the use of quetiapine for the psychiatric disorder and insomnia. Moreover, there were no psychiatric symptoms that would have necessitated inpatient level care-as the health plan noted in the denial determination. 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 the 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.

The application of OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 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. Thus, medical necessity for the inpatient rehabilitation substance use disorder treatment is not met in this case scenario. This answer is consistent with ASAM (American Society of Addiction Medicine) Criteria, the scientific literature and published guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review. The patient had presented with a level of stability and no general medical issues or co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care. He did not need 24-hour monitoring or the structure of an inpatient setting in order to receive effective substance use disorder treatment. He readily engaged with evidence-based psychosocial treatment and was involved with peer supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports. Thus, the health plan's determination is reasonable in this case scenario.

This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Guidelines, referenced below.