Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient rehabilitation admission. 
The insurer denied the Inpatient rehabilitation admission.
The denial is upheld.

The patient is a adult male. He was referred with admission to inpatient rehabilitation and substance use disorder treatment beginning to primarily address substance use disorder with alcohol, opioid and cocaine use, as well as intermittent use of Xanax. The patient has no history of withdrawal seizures or delirium tremens. He was in medication assisted treatment with Suboxone, but had continued to use 3 to 4 bags of heroin with IV (intravenous) administration. He had been using one pint of liquor and beer together with daily use of one gram of cocaine, as well as taking his Suboxone. He had past treatment experience with at least two detoxification treatment episodes and the ongoing MAT (medication-assisted treatment). His drug screen was negative and his blood alcohol level was zero with a CIWA (clinical institute withdrawal assessment) scale score of 0 and a COWS (clinical opiate withdrawal scale) scale score of 1 reflecting no withdrawal symptoms.

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. Psychiatric evaluation had been provided and affirmed that the patient had co-occurring psychiatric disorders with anxiety and insomnia as a focus of treatment.

Throughout the inpatient stay, the patient remained stable and engaged with the treatment regimen. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. He had been medically cleared for aftercare, a bed was secured for continued treatment with sober living and residential rehabilitation treatment. The patient was discharged for continued rehabilitation substance use disorder treatment with check in on the following day.

The health plan denied coverage of the admission on the basis of New York State LOCADTR (level of care for alcohol and drug treatment referral) 3 Criteria indicating that residential level care was appropriate. Additionally, the denial indicated that the patient had no significant general medical issues or drug or alcohol withdrawal requiring inpatient level care. The denial determination referenced the psychiatric comorbidity as not requiring inpatient level care, and indicated that the patient had reasonable motivation for substance use disorder treatment with lower level care indicated.

The appeal was on the basis of multiple past treatment episodes with no "clean" time and a lack of coping skills, indicating that New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) Criteria were met for inpatient level rehabilitation treatment. The appeal also indicated that the lack of psychotic features was not a valid reason to deny the requested level of care.

No, the Inpatient rehabilitation admission was not medically necessary.
The patient received inpatient level rehabilitation treatment. He was referred for treatment after failing to remain abstinent while receiving Suboxone treatment and other services.  As the health plan asserts, the patient had no significant general medical or serious symptoms of psychiatric comorbidity, and presented with no complicated withdrawal or safety concerns such as suicidality or aggressive impulses. He was motivated to engage in rehabilitation treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. Thus, the patient did not meet New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) Criteria, as the health plan asserts in the denial.

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. During his inpatient stay, there were no complicating treatment issues that would have warranted inpatient level of care, structure or 24-hour monitoring. The application of 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 (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 also asserts. Thus, the argument on appeal noted below is not consistent with LOCADTR (level of care for alcohol and drug treatment referral) Criteria and medical necessity for the inpatient level care for substance use disorder rehabilitation treatment is not met in this case scenario, consistent with ASAM (American Society of Addiction Medicine) Criteria, the scientific literature and published guidelines, referenced below.

Yes, the health plan has acted reasonably, with sound medical judgment and in the best interest of the patient.
The patient in this case scenario is not clinically appropriate for an inpatient level of care for the time interval under review. The patient had presented with a level of stability that included no significant withdrawal symptoms or biomedical issues and no co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care. He did not need the monitoring or the structure of an inpatient setting in order to receive effective substance use disorder rehabilitation treatment. Moreover, he was motivated for treatment and was already involved with Suboxone maintenance treatment and peer-supported recovery groups that could have been provided in a less restrictive treatment setting in order to address the comorbid cocaine and alcohol use disorders and co-occurring psychiatric disorders with anxiety and insomnia.

Thus, the health plan's determination is reasonable in this case scenario-noted below. 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 New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Guidelines/Criteria, referenced below.