Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male. He was self-referred for inpatient rehabilitation and substance use disorder treatment. The patient has long-standing substance use disorders with stimulant (cocaine)- and opioid (heroin)-class substances with prior treatment with a chronic relapsing course. The patient has no history of withdrawal seizures or delirium tremens. The 
patient has a history of substance use disorder treatments with detoxifications and rehabilitation treatment but no sustained sobriety or abstinence despite receiving methadone maintenance with medication assisted treatment at 80 milligrams daily. Drug screen was positive and consistent with history. The patient's 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 engaged in substance use disorder rehabilitation treatment. He was prescribed his usual dose of methadone. Throughout his inpatient rehabilitation stay, the patient remained stable with mental status and remained engaged with the 
treatment regimen. The patient completed the program with discharge and transfer with plans for clinically appropriate aftercare with extended or long-term residential treatment, plans to arrange for sober living, and a coordinated referral back to the methadone clinic for continued methadone maintenance treatment.

The Inpatient Substance Abuse Treatment was not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with stimulant/cocaine and opioid and tobacco/nicotine use disorders. He self-referred and received inpatient level rehabilitation treatment with continued use of methadone. He readily engaged in treatment and had no biomedical or psychiatric treatment issues that warranted inpatient level care. During the time interval under review, the patient was noted to be in no apparent distress other than insomnia that responded to treatment, and he displayed reasonable functioning and active participation in treatment including positive interactions with staff and peers. Throughout his 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 nursing monitoring, as the health plan asserts. The application of NY (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, also as the health plan asserts. Thus, medical necessity for the inpatient substance use rehabilitation treatment for the dates of service under review is not met in this case, consistent with American Society of 
Addiction Medicine (ASAM) Criteria, the scientific literature, and published guidelines, referenced below, and with the required 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. Therefore, the requested Inpatient substance use rehabilitation treatment is not medically necessary for this patient.