Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Substance Use inpatient rehabilitation treatment (5 days) 
The insurer denied: Substance Use inpatient rehabilitation treatment (5 days) 
The denial is: Upheld

The patient is a male who was self-referred with admission to inpatient rehabilitation and substance use disorder treatment to address substance use disorders with alcohol and cocaine. The patient had no history of blackouts or withdrawal seizures or delirium tremens. He had been using up to 2 pints of liquor daily with intermittent use of $100 worth of cocaine with a frequency of three to six times per week with intranasal administration. He had multiple past treatments with residential and outpatient substance use treatment with the most recent detoxification and the most recent residential level treatment. His drug screen was positive for cocaine with no significant withdrawal symptoms. He reported craving and urges to use. He was also tobacco dependent and an every-day smoker.

Throughout the inpatient stay, the patient remained stable and engaged with the treatment. He was noted to be respectful of peers and staff. He received intensive rehabilitation services, monitoring, and structure provided within the inpatient treatment program including 24-hour monitoring. The rehabilitation treatment proceeded without incident or complication, and the patient was transferred to a sister program for continued rehabilitation services. The subject under review is the medical necessity for substance use inpatient rehabilitation treatment (5 days).

The health plan's determination is upheld.

The requested health service/treatment of Substance Use inpatient rehabilitation treatment (5 days) was not medically necessary for this patient. The patient's treatment could have been safely provided at a lower level of care in this case scenario.
The patient in this case presented with continuous daily use of alcohol and intermittent and weekly use of cocaine; he did not experience general medical complications or present with severe symptoms of a co-occurring psychiatric disorder, or abnormal findings on examination or laboratory assessments, or severe withdrawal symptoms that would have warranted inpatient level services. His risk for withdrawal complications including seizures and delirium tremens were minimal considering his history, and he did not pose a safety risk that would have warranted the requested level of care.
The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cocaine. Moreover, the patient had been evaluated and cleared with regard to safety concerns and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance, or general medical concerns that would have warranted an inpatient level admission and treatment. 
Thus, the requested services were not medically necessary in this case scenario. Any indicated treatment for alcohol or cocaine use disorder in this case could have been provided, as clinically appropriate, at a lower level of care in keeping with the Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria. This answer is also consistent with published guidelines, the scientific literature, and American Society of Addiction Medicine (ASAM) criteria.