Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Substance Use Rehabilitation Services
The insurer denied inpatient Substance Use Rehabilitation Services.
The determination is upheld

The patient was transferred from detoxification treatment for inpatient rehabilitation substance use disorder treatment in order to address substance use disorder with alcohol, opioid, cocaine and cannabis class substances of abuse. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a history of substance use disorder with multiple prior detoxification treatments and participation in a methadone maintenance treatment program with relapses or continued use. He reported the daily use of alcohol with up to two pints of wine and two beers; and up to two marijuana blunts per day; and one bag of heroin two times per week together with intermittent use of crack cocaine.
The patient has a history of a psychiatric disorder and treatment for bipolar disorder with no current treatment and no history of psychiatric hospitalization.
There were no acute general medical issues in this case; the patient had been medically screened at the time of his admission for substance-related treatments, and generally had normal vital signs and no severe withdrawal or post-acute withdrawal symptoms though he reported craving and urges to use substances. He was a light every-day smoker.
Evaluation on admission for inpatient level services revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for rehabilitation treatment. The patient was described as cooperative with fluent speech and euthymic mood, and with fair insight with regard to the substance use disorder. He had no evidence of acute mania, thought disorder, psychosis, perceptual disturbance or severe cognitive impairment. He did not report suicidal or homicidal ideation. He reported insomnia, but no other prominent somatic concerns.
The patient was admitted to inpatient rehabilitation treatment with replacement of vitamins and comfort medications, as well as continued use of methadone at 40 milligrams (mg) per day. He was provided 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.
Throughout the inpatient stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program. The patient was social with peers and participating actively in treatment with continued risk for relapse; the patient had no severe withdrawal symptoms or post-acute withdrawal symptoms, and he had no complications with respect to biomedical, general medical, emotional or other treatment domains. Progress notes reflected stable mood with sleep, appetite and energy that were okay with the use of Benadryl as needed. The patient was discharged with plans to immediately return to outpatient level treatment with the methadone program and with recommendation for involvement in recovery groups.
The health plan documents, appeal documents, and correspondence from the health plan and treatment facility, as well as case records and summary, and the health plan's rationale for the denial of certification for coverage of the requested treatment, were reviewed. This case is a New York State mandated review with the application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines.
At issue is the medical necessity of inpatient Substance Use Rehabilitation Services.

The requested health service/treatment of substance use inpatient rehabilitation treatment was not medically necessary for this patient.

The patient presented with substance use disorders with the use of alcohol, cannabis, opioid and cocaine class substances while participating in a methadone maintenance treatment program. He received inpatient detoxification treatment transitioning to inpatient level rehabilitation treatment. He readily engaged in treatment with continued use of methadone and comfort medications. During the time interval under review, the patient was noted to be in no apparent distress with active participation in treatment including positive interactions with staff and peers. There were no treatment issues or biomedical or co-occurring psychiatric disturbances that would have warranted continued inpatient level of care. 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.
Medical necessity is not met in this case scenario consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below, as well as the application of NY State OASAS LOCADTR Criteria.