Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Substance Abuse Inpatient Rehabilitation Admission
The insurer denied the substance abuse inpatient rehabilitation admission.
The denial is upheld.

The patient is an adult male. He was admitted to inpatient level services for treatment of substance use disorder with cannabis and phencyclidine (PCP) class substances. The patient was referred in the context of legal issues and recent release from 65 days of incarceration for charges of assault. After his release, the patient had begun using PCP, putting himself at risk for re-incarceration, and putting others at risk in view of his history of violence and impulsive aggression. The patient was externally motivated to enter substance abuse rehabilitation treatment with a court date pending. There are co-occurring psychiatric disorders diagnosed in this case including anxiety-depression with poor impulse control associated with bouts of anger. The patient has trauma history with physical and emotional abuse, and complicated grief related to the death of his brother. The patient has prominent history of legal issues including the recent incarceration with court date pending.

The patient's Mental Status Examination revealed no severe symptoms, and the patient was cooperative. He exhibited normal speech, thought processing and functioning. He lacked coping skills and demonstrated limited insight and impaired judgment due to the substance use disorder and his maladaptive coping skills. He reported sleep disturbance with nightmares. He was noted to be at high-risk for impulsive aggression, but denied suicidal ideation, homicidal ideation or aggressive impulses.

Comfort medications were available as needed, and he was prescribed an albuterol inhaler on a prn (as needed) basis together with Claritin and Allegra.

The patient engaged in substance use disorder treatment with active involvement in group and educational sessions, as well as other therapeutic interventions to support healthy living and the development of sober supports. In this regard, the patient worked on coping skills and a relapse prevention plan with the identification of triggers including the negative influence of the social environment and peers. Additionally, there was focus on anger management. The patient did complete the program, and he was discharged with referral for residential treatment.

The health plan's denial of coverage was on the basis of medical necessity and LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Criteria, indicating that the patient did not warrant inpatient level services and had no general medical, psychiatric, or safety issues that would require inpatient level monitoring. The denial determination indicated that the patient was motivated and had no serious withdrawal symptoms.

The appeal was on the basis of LOCADTR Criteria, with reference to the clinical features, prior treatment episodes with relapses, and the mental status findings including high-risk for impulse aggression.

The substance abuse inpatient rehabilitation admission was not medically necessary.

The inpatient substance abuse rehabilitation treatment in this case scenario was amenable to treatment at a lower level of care. The patient was externally motivated and able to effectively engage in rehabilitation services, and the patient did not need the structure or monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have required inpatient level services and treatment. Moreover, the patient was motivated to participate in rehabilitation treatment, as noted in the clinical summary. Thus, the requested inpatient admission was not medically necessary for this patient.