Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol abuse 
Treatment: Inpatient Rehabilitation 

The insurer denied the inpatient rehabilitation. The denial is upheld. 

The patient is a female referred for inpatient rehabilitation and substance use disorder treatment to address use of alcohol and stimulant (cocaine) class substances. The patient has no reported history of withdrawal seizures or delirium tremens but does have a seizure disorder treated with Dilantin and Neurontin. Her history of substance use included use of one and one-half pints of vodka plus beer daily and $20 worth of crack cocaine. The patient has a history of multiple prior treatment episodes with relapses including at least eight detoxification treatment episodes and three rehabilitation treatment episodes with only one outpatient aftercare involvement. She was admitted/transferred for rehabilitation treatment following detoxification treatment. 

The patient has a history of psychiatric disorder best characterized as schizoaffective disorder, bipolar mood disorder type with insomnia treated risperidone and mirtazapine. There was history of psychiatric hospitalizations and non-compliance with mental health treatment, but no suicidal or self-harming behavior. 

The patient had no acute general medical issues; she was medically screened upon admission. Chronic conditions included hypertension, dyslipidemia type II diabetes mellitus, and coronary artery disease with stents, as well as bronchial asthma. She was tobacco dependent at one pack per day for 30 years. 

Evaluation on admission revealed a mental status examination that reflected motivation for rehabilitation treatment, but limited insight, impaired judgment, and poor control of impulses. The patient was described as cooperative with fluent speech and organized thought processing. She had no severe symptoms such as mania, formal thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. She did not report suicidal ideation or aggressive impulses. 

No, the proposed treatment and the requested benefit of inpatient substance abuse rehabilitation treatment was not medically necessary for this patient. 

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use disorders. She had received detoxification treatment. She was medically screened and had no acute general medical issues. She received inpatient level rehabilitation treatment. She readily engaged in treatment and had no biomedical (withdrawal symptoms or signs) or acute psychiatric treatment issues with continued use of risperidone and mirtazapine for the psychiatric disorder and insomnia. 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 NY State OASAS 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 asserts. Thus, medical necessity for the inpatient rehabilitation substance use disorder treatment is not met in this case scenario. This answer is consistent with the American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.