Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Inpatient Rehabilitation

The patient has a history of opioid use disorder and depression who was admitted for inpatient rehabilitation level of care. Admission urine drug screen was positive for opiates and negative for all other drugs tested. The patient reported inhalation of heroin approximately five bags every two days and was also using buprenorphine 1 to 2 times per week one strip daily. On initial review of systems, the patient reported diarrhea and nervousness, but denied having numerous other symptoms including pulse irregularity, seizures, sweat, vomiting, muscle weakness, dizziness, breathing difficulty, confusion. There are documents included in the records that have numerous unanswered questions. For example, there is a managed-care certification questionnaire where issues such as social environment, supports, education, occupational, housing, health, legal, trauma, financial are all left entirely blank. The patient had a slightly elevated pulse of 104 on one occasion on the date of admission but had normal vital signs on another assessment. Further documentation indicates that the patient had a stable living environment.

The health plan's determination is upheld. The inpatient rehabilitation was not medically necessary for this patient. Using the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Level of Care tool, the recommended level of care is:
Outpatient Treatment with Medication Assisted Treatment (MAT).
The patient did not require immediate hospitalization for a life-threatening medical condition or a severe psychiatric crisis. Opioids were the substance the person was using that had the most potential to cause harm to self or others. The patient clearly met criteria for an opioid use disorder. The patient was not in full remission from a substance use disorder. The patient was not using substances with a risk of serious medical complications from withdrawal. The patient did not have serious medical symptoms that needed to be managed in an inpatient rehabilitation setting for substance use disorder treatment to be effective. The patient did not have serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation setting for the substance use disorder treatment to be effective. Clinical documentation does not establish that the patient was using in hazardous situations, and amounts of frequencies likely to imminently cause severe physical or emotional harm to self or others. The chart does not clearly establish that the patient had interpersonal or personal skills deficits. Medication assisted treatment is presumed to be available in the community. Clinical documentation does not establish that the patient was having problems adequately performing responsibilities. This patient had an opioid use disorder. The patient had good sober supports. There was no unstable medical or psychiatric issue requiring 24 hour access to medical and nursing care. Opioids are not associated with a life-threatening withdrawal syndrome and there was no evidence that the patient had severe withdrawal symptoms such as intractable nausea and vomiting or electrolyte abnormalities. The patient could have been safely and effectively treated at a lower level of care.